Endoscopic frontal sinus obliteration: a new technique for the treatment of chronic frontal sinusitis.

OBJECTIVES: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic technique for frontal sinus obliteration. STUDY DESIGN AND SETTING: Retrospective case-control. Thirty-five patients underwent frontal sinus obliteration using either an endoscopic (n=10) or conventional osteoplastic flap (n=25) technique from 1994 to 2004 at an academic medical center. RESULTS: Patients undergoing endoscopic obliteration had less blood loss (P = 0.006), decreased operative time (P = 0.016), and a shorter hospital stay (P = 0.003) compared to osteoplastic control subjects. All 3 surgical complications occurred in the control group. No patients required additional surgery for frontal sinusitis. CONCLUSIONS: The endoscopic approach to frontal sinus obliteration appears to reduce patient morbidity and should be considered in the surgical management of advanced frontal sinus disease. SIGNIFICANCE: This is the first report of a minimally-invasive technique for frontal sinus obliteration.     

Use of anteriorly based pericranial flap in frontal sinus obliteration.

OBJECTIVE: In an era of endoscopic sinus surgery, frontal sinus obliteration continues to remain an important treatment option in chronic frontal sinus disease. Numerous avascular obliterative materials including fat, muscle, cancellous bone, and hydroxyapatite have been used in this procedure. In this article, we describe a vascularized anteriorly based pericranial flap to obliterate frontal sinus. STUDY DESIGN: Retrospective chart review of patients referred to tertiary care hospital between 1996 and 2003. METHODS: Records of the patients who underwent this procedure were reviewed. Demographics, indications, and immediate and late complications were recorded. A phone questionnaire was used to assess patient satisfaction with the outcome. RESULTS: A total of 12 patients underwent frontal sinus obliteration with this technique. Mean follow-up was 40 months. None of the patients developed recurrent frontal sinusitis. All of the patients were pleased with the outcome. CONCLUSION: Pericranial flap is a highly vascularized flap that is easily harvested and is an effective and viable modality for obliterating frontal sinus. EBM rating: C-4.     

Osteoplastic flap for obliteration of the frontal sinus: Five years’ experience

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses. (Otolaryngol Head Neck Surg 1999;121:731-5.)     

Osteoplastic flap for obliteration of the frontal sinus: five years' experience.

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses.     

Image-guided frontal trephination: a minimally invasive approach for hard-to-reach frontal sinus disease.

OBJECTIVES: Peripherally located frontal sinus pathology may be unreachable with standard endoscopic techniques. Patients with superiorly or laterally based lesions often undergo osteoplastic flap with or without obliteration. Image-guided frontal trephination (IGFT) can localize pathology and provide excellent exposure. We present 13 patients in whom this technique was applied. STUDY DESIGN: Medical records of 13 patients undergoing IGFT were retrospectively reviewed. RESULTS: The patients' mean age was 49.2 years, (range 14-79); follow-up time was 29.9 months (range 12-39). Indications for IGFT were superiorly or laterally based mucoceles (3), fibrous dysplasia or osteoma (3), type 4 frontal cells (3), and frontal recess stenosis or ossification (4). In five patients, IGFT was combined with endoscopic transethmoid frontal sinusotomy; eight patients were treated through a trephination approach, and three patients underwent trephination with unilateral frontal sinus obliteration. One patient required revision; all others remain symptom free. CONCLUSIONS/SIGNIFICANCE: IGFT offers an attractive alternative to osteoplastic flap.     

Radiographic evaluation and diagnosis of the failed frontal osteoplastic flap with fat obliteration

In the absence of evidence of suppurative disease, clinical assessment of the symptomatic patient after frontal osteoplastic flap with fat obliteration is difficult because the cause of the pain is often neuralgic or from chronic vascular headache. Among 59 patients who have undergone this procedure at our institution since 1979, four required revision surgery. These patients were evaluated by computed tomographic and magnetic resonance scans, and the radiographic findings were compared with those present in 20 asymptomatic subjects. On the basis of the results of this study, we believe we can objectively identify those patients with chronic pain in whom the operation has been unsuccessful. A review of our experience with this procedure is presented along with criteria that enable early diagnosis of recurrent disease in the frontal sinus after osteoplastic sinusotomy.     

Treatment of frontal sinus mucoceles with the osteoplastic flap technique.

The osteoplastic flap technique for treating frontal sinus mucoceles is described. This procedure has the advantages of: being a direct approach, which allows exposure of the entire sinus, provides complete obliteration of the sinus to prevent recurrence of the sinus disease, and prevents blind curettage of any exposed dura mater; leaving no facial deformity after the operation; being a relatively atraumatic procedure with low morbidity and minimum postoperative care; and allowing simultaneous surgery on both frontal sinuses when indicated.     

Quality-of-life outcomes after osteoplastic frontal sinus obliteration.

Frontal sinusitis and its treatment remain controversial. Although several authors have evaluated the results of traditional endoscopic sinus surgery, few have assessed patient outcomes and quality of life after osteoplastic frontal sinus obliteration. This retrospective study evaluates these outcomes in a postoperative review and questionnaire of 39 patients treated at the University of Washington from 1991 to 1994. Most patients were satisfied with the results of this procedure, had significant improvements in their Chronic Sinusitis Survey scores, and reported decreased clinic visits and antibiotic use. However, approximately half thought nonsurgical treatments were more effective and continued to require other medical therapy; 30% required additional surgical intervention. Such outcomes may reflect the ineffectiveness of frontal sinus obliteration to treat the chronic symptoms of patients affected by the refractory underlying disease process of chronic sinusitis; however, despite these mixed results, we found a significant decrease in annual days of lost work or activity in this study group after osteoplastic obliteration.     

Frontal Sinus Surgery Anterior to the Ethmoid Bulla

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.     

Evaluation of hydroxyapatite cement for frontal sinus obliteration after mucocele resection

OBJECTIVES: To retrospectively evaluate our experience with frontal sinus obliteration using hydroxyapatite cement (BoneSource; Stryker Biotech Europe, Montreux, Switzerland) and compare it with fat obliteration over the approximate same period. Frontal sinus obliteration with hydroxyapatite cement represents a new technique for obliteration of the frontal sinus after mucocele resection. METHODS: Exploration of the frontal sinus was performed using bicoronal, osteoplastic flaps, with mucosal removal and duct obliteration with tissue glue and muscle or fascia. Flaps were elevated over the periorbita, and Silastic sheeting was used to protect the BoneSource material from exposure as it dried. The frontal table was replaced when appropriate. RESULTS: Sixteen patients underwent frontal sinus obliteration with fat (fat obliteration group), and 38 patients underwent obliteration with BoneSource (BoneSource group). Fat obliteration failed in 2 patients, who underwent subsequent BoneSource obliteration, and none of the patients in the BoneSource group has required removal of material because of recurrent complications. Frontobasal trauma (26 patients [68%] in the BoneSource group and 9 patients [56%] in the fat obliteration group) was the most common history of mucocele formation in both groups. Major complications in the BoneSource group included 1 patient with skin fistula, which was managed conservatively, and 1 patient with recurrent ethmoiditis, which was managed surgically. Both complications were not directly attributed to the use of BoneSource. Contour deficit of the frontal bone occurred in 1 patient in the fat obliteration group and in none in the BoneSource group. Two patients in the fat obliteration group had donor site complications (hematoma and infection). Thirteen patients in the BoneSource group had at least 1 prior attempt at mucocele drainage, and no statistical relation existed between recurrent surgery and preservation of the anterior table. CONCLUSION: Hydroxyapatite is a safe, effective material to obliterate frontal sinuses infected with mucoceles, with minimal morbidity and excellent postoperative contour.     

Endoscopic modified Lothrop procedure for the treatment of chronic frontal sinusitis: a systematic review.

OBJECTIVE: We sought to assess the safety and efficacy of the endoscopic modified Lothrop procedure (EMLP), performed either wholly intranasally or in combination with an external approach, against the osteoplastic flap (OPF) procedure with or without fat obliteration. METHODS: All original, published studies on the EMLP and the OPF, with or without fat obliteration, were identified by searching Current Contents, Embase, MEDLINE, and The Cochrane Library. The search strategy for OPF was date-restricted to articles published after 1979 until February 2001. For both EMLP and OPF, only studies of patients diagnosed with chronic frontal sinusitis were included for review. English-language reports detailing randomized controlled trials, controlled clinical trials, case series, or case reports were included. RESULTS: The limited comparative data suggested that EMLP caused fewer adverse postoperative outcomes but was more likely to generate a perioperative cerebrospinal fluid leak than OPF. However, none of the morbidity traditionally associated with OPF was evident after EMLP. EMLP appeared to have a shorter operative time and a lower perioperative blood loss than OPF, but little could be determined regarding the long-term efficacy and durability of EMLP because of the relatively short follow-up of the majority of the studies. CONCLUSION: The evidence base for EMLP was deemed inadequate to assess its safety and efficacy, and an audit of the procedure was recommended. Additional clinical recommendations were made regarding the development and current practice of EMLP during this audit phase.     

Frontal sinus obliteration with the pericranial flap.

BACKGROUND: Frontal sinus obliteration is often accomplished by autologous grafts such as fat, muscle, or bone. These avascular grafts carry an increased risk of resorption and infection as well as donor site morbidity. Vascular regional flaps may be used to obliterate small sinuses with less morbidity. OBJECTIVES: To review our experience with the use of the pericranial flap for obliteration of the frontal sinus. METHODS: The records of 10 patients who underwent obliteration of the frontal sinus with the pericranial flap were reviewed. Demographics, indications for frontal sinus obliteration, immediate and late complications, and long-term outcome were recorded. These results were compared with those in the current literature. RESULTS: Ten sinuses were obliterated with the pericranial flap. Indications included frontal sinus mucocele, mucopyocele, frontal sinus osteomyelitis, and frontal sinus fracture. The median follow-up was 3 years. There was 1 short-term complication of persistent headache for 1 month, and there was asymptomatic recurrence of a neofrontal sinus in 1 case. CONCLUSIONS: The pericranial flap is a vascularized local flap that is easily harvested. The use of the pericranial flap avoids donor site morbidity associated with free fat or cancellous bone grafts. The pericranial flap arms the head and neck surgeon with an effective alternative to other methods of frontal sinus obliteration.     

Aggressive endoscopic resection of inverted papilloma: an update.

OBJECTIVE: Endoscopic resection has been proposed for sinonasal inverted papilloma (IP). Our objective was to determine the efficacy of aggressive endoscopic resection of IP. METHODS: Retrospective analysis was performed on patients undergoing endoscopic resection of IP at the University of Virginia between 1990 and 1996. Total ethmoidectomies, wide maxillary antrostomies, frontal recess explorations, sphenoidotomies, and turbinate resection were performed as required. Once all visible papilloma was removed, residual mucosa was removed by using a diamond burr to polish bone at the site of origin. RESULTS: Twenty-one patients were treated with endoscopic resection of IP. Only 1 of 21 patients had an adjunctive external procedure (an osteoplastic flap without obliteration). Average follow-up was 41.9 months after initial aggressive endoscopic resection at the ureterovesical angle. Recurrences occurred in 19% (4/21) of patients. One of the 4 had two recurrences. Recurrences occurred in 16 months or less, except for one noted at 35 months and another at 56 months. CONCLUSIONS: Aggressive endoscopic resection of IP by experienced rhinologists is an acceptable treatment.     

Single-stage strategy for management of anterior table frontal sinus fractures involving the frontal sinus outflow tract

Treatment of frontal sinus fractures has been controversial for years. The aim of treatment, besides cosmetic restoration, is to create a “safe” sinus especially in those with evidence of injury to the frontal sinus outflow tract. Early and late complications include acute and chronic sinusitis, mucocoele and mucopyocoele formation, brain abscess and osteomyelitis. Osteoplastic flap with frontal sinus obliteration or cranialisation is most commonly performed. With the advent of modern endoscopic and advanced imaging techniques, endoscopic sinus surgery for treatment of diseases of the frontal sinus is ever increasing. In this paper, we describe our successful experience using a single-stage, combined open and transnasal endoscopic technique in management of patients with anterior table frontal sinus fractures involving the frontal sinus outflow tract.     

Modified Subtotal Lothrop Procedure for Extended Frontal Sinus and Anterior Skull Base Access: A Cadaveric Feasibility Study with Clinical Correlates

Objective The endoscopic modified Lothrop procedure (EMLP) is an established approach for recalcitrant frontal sinus disease and anterior skull base exposure. However, in select cases, this technique may involve unnecessary resection of sinonasal structures. In this study, we propose a modification of the EMLP, termed the modified subtotal-Lothrop procedure (MSLP), to access the anterior skull base and complex frontal sinus disease for which access to the bilateral frontal sinus posterior table is required.Methods A cadaveric dissection with photo documentation was performed at an academic medical center on four cadaver heads using standard endoscopic techniques to demonstrate the MSLP and its feasibility.Results The endoscopic MSLP allowed ample access for instrumentation in each of the dissections using a 30- or 70-degree endoscope. Adequate bilateral access to the posterior table of the frontal sinus was gained in all cases without the need for dissection of the contralateral frontal sinus recess (FSR).Conclusion The MSLP appears to be a feasible technique for exposure of the anterior skull base and accessing complex frontal sinus pathology. This modification provides similar anterior skull base exposure and surgical maneuverability as the EMLP while limiting surgical dissection to one FSR, thereby preserving as much of the natural mucociliary drainage pathways as possible.     

Frontal bone defect with frontal sinus mucopyocele

For this patient's treatment, all three consultants advise against the Lynch-type frontoethmoidectomy procedure, with or without mucoperiosteal flap reconstruction of the nasofrontal duct. Treatment plan: Culture and sensitivity of pus; 2-3 weeks of intravenous antibiotics followed by osteoplastic flap fat obliteration of frontal sinus; delayed defect repair with methyl methacrylate (Montgomery). Trephination followed by treatment with local and systemic antibiotics (Donald); removal of infected bone and soft tissue (sinus collapse) and delayed defect repair in 6-12 months (Donald, Calcaterra) with metylmethacrylate (Donald) or in situ cured silicone elastomer (Calcaterra).     

Frontal sinus fracture following osteoplastic frontal sinus obliteration

A patient who sustained frontal sinus fracture and who earlier had undergone an osteoplastic fat obliteration procedure is described. The literature is reviewed and recommendations are made for management of this and other cases of frontal sinus fractures with posterior table involvement.     

Management of acute complicated sinusitis: a 5-year review.

Acute sinusitis is a relatively common problem; however, sinusitis associated with a complication is less frequent. Currently there is debate as to whether acute complicated sinusitis should be managed by frontal sinus trephine and sinus washout or by immediate frontoethmoidectomy/functional endoscopic sinus surgery. To assess the effectiveness of frontal sinus trephine in the management of acute complicated frontal sinusitis, we reviewed all patients admitted to Groote Schuur Hospital with acute pansinusitis (includes frontal, maxillary, and ethmoid) from 1989 to 1993. Eighty-seven patients were admitted, of whom 43 were treated medically and 44 were treated surgically. Of the surgical patients 38 had frontal trephines and management of associated complications. Thirty (80%) of the patients who received frontal trephines recovered without further surgery, and 8 required further sinus surgery for persistent disease. Frontal trephine with management of associated complications is an acceptable management option for patients with acute complicated pansinusitis. Frontoethmoidectomy or functional endoscopic sinus surgery can be held in reserve for those patients with persistent disease that does not resolve after the initial frontal trephine.     

Revision endoscopic frontal sinus surgery with surgical navigation.

BACKGROUND: Revision surgery of the frontal sinus remains one of the most difficult operations for the endoscopic surgeon. Most agree that knowledge and recognition of its complex anatomy and sparing of frontal recess mucosa are keys to a successful operation. The use of surgical navigation systems may allow for more precise dissections and greater rates of frontal recess patency. METHODS: Retrospective review of all patients undergoing revision endoscopic frontal sinus surgery with surgical navigation was performed with a minimum 24-month follow-up. RESULTS: Sixty-seven patients underwent revision endoscopic frontal sinus surgery with surgical navigation. The average follow-up was 32 months. Fifty-eight (86.6%) had a patent frontal recess and significant subjective improvement in symptoms. No patient underwent external frontal sinus obliteration, and there were no major complications. CONCLUSIONS: Endoscopic techniques with surgical navigation are effective in revision frontal sinus cases. The dissection of remnant agger nasi, obstructing frontal and supraorbital cells are necessary to widen the anterior-posterior as well as the medial-lateral dimensions of the recess. Computer navigational systems appear to serve as a valuable adjunct in preoperative planning and safe intraoperative dissection.