Long-term results after endoscopic sinus surgery involving frontal recess dissection

OBJECTIVE: To assess long-term follow-up on a cohort of patients who underwent endoscopic frontal sinus surgery with identification and preservation of the natural frontal outflow tract. STUDY DESIGN AND SETTINGS: Retrospective chart review, telephone interview, and endoscopic evaluation on a previously studied cohort of patients at a university affiliated medical center. RESULTS: Two hundred patients who underwent endoscopic frontal sinus surgery were previously studied and reported after short-term (mean = 12.2 mo) follow-up. One hundred fifty-two (76%) patients were available for long-term (mean 72.3 mo) follow-up and assessment of subjective symptoms. Fifty-seven of 152 (37.5%) patients also had nasal endoscopy for evaluation of objective findings. The percentage of patients responding to telephone interview reporting overall improvement after surgery was 92.4%. Endoscopic assessment revealed patency of the frontal sinus in 67.6% of the patients after initial surgery. Thirteen additional patients had patent sinuses after revision procedures, bringing overall patency rate to 71.1%. We found statistically significant correlation of asthma and smoking and poor subjective and objective outcome. CONCLUSION: Long-term assessment of subjective and objective findings in our previously reported cohort of patients who underwent frontal sinus surgery indicates that the frontal sinus, similar to any other sinus, can be successfully treated surgically by preserving the natural frontal sinus outflow tract.     

Use of computer-aided surgery for frontal sinus ventilation

OBJECTIVES: To review our experience and evaluate the utility of computer-aided surgery for frontal sinus and frontal recess disease. STUDY DESIGN: A retrospective review of 31 consecutive patients undergoing computer-aided surgery for frontal sinus ventilation. METHODS: The hospital charts of 31 patients were reviewed. Previous sinonasal procedures, etiology of sinonasal disease, preoperative computed tomography (CT) scan findings, preoperative symptoms, endoscopic and intraoperative findings, type of frontal sinus ventilation procedure, complications, imaging system registration method or accuracy, and postoperative course were noted. RESULTS: In all 31 patients the surgery was successfully completed, and no intracranial or orbital complications were encountered during or after surgery. Six patients required additional surgery including revision transnasal endoscopic frontal sinus ventilation or osteoplastic flaps with fat obliteration. In the six cases requiring additional surgery, disease severity, most commonly, aspirin triad disease, predisposed to failure of frontal sinus ventilation. CONCLUSIONS: Computer-aided surgery is a useful adjunctive device for safe, efficient identification and surgery of the frontal sinus. However, it is not a replacement for sound surgical technique, anatomical knowledge, and experience. In particular, patients with aspirin triad disease with frontal recess and frontal sinus involvement are highly suited for computer-aided surgery and thorough removal of disease, although failures occur despite this technique. The long-term benefit of computer-aided surgery of the frontal sinus has not yet been demonstrated by this or other studies.     

Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure

OBJECTIVES/HYPOTHESIS: Until recent years, the osteoplastic flap with frontal sinus obliteration has been the gold standard for recalcitrant frontal sinusitis. The present series evaluated the role of the endoscopic modified Lothrop procedure, which has recently been advocated as an alternative. STUDY DESIGN: Prospective non-randomized interventional case series. METHODS: The study prospectively assessed 83 consecutive patients who underwent endoscopic modified Lothrop procedure. The mean age was 52.4 years (SD = 13.6 y) with a male-to-female ratio of 3:1. Patients had a mean of six previous sinus surgical procedures with 17 patients having undergone previous frontal sinus obliteration with mucocele formation. Seventy-six patients (91%) had frontal pain or headache as their primary presenting symptom, with 72 having nasal discharge. There were 14 patients who presented with 17 complications of frontal sinus disease. There were eight erosions of the posterior table of the frontal sinus with extension of the mucocele intracranially, seven orbital complications, and one cerebrospinal fluid leak. Twenty-four patients (30%) had fungus cultured from their sinuses at the time of surgery. RESULTS: Six of the 83 patients (7%) developed frontal ostium stenosis resulting in a 93% primary success rate after an average follow-up of 21.9 months (SD = 6.1 mo). These patients all underwent a revision modified Lothrop procedure and had a patent frontal ostium at their last review. Twenty-one patients (25%) developed recurrent symptoms, which were managed medically. Of these 21 patients, 9 with previously diagnosed fungal sinusitis developed mucosal changes again in their frontal sinuses, but their ostia have remained patent. Four patients have had recurrent infections in the frontal sinuses, and three patients with aspirin-sensitive asthma and polyps have developed polyps again in their frontal sinuses. Five patients continued to have frontal pain without radiological evidence of further frontal disease. No patients required an osteoplastic flap procedure. CONCLUSION: The endoscopic Lothrop procedure is a successful short-term management option for recalcitrant and complicated frontal sinusitis caused by a wide range of diseases.     

鼻内镜下额窦手术

目的：探讨应用鼻内镜进行额窦手术。方法：总结201例鼻内镜下额窦手术。其中额窦炎症性病变190例，额窦粘液囊肿10例，额窦骨瘤1例，合并其它鼻腔病变247侧。术前行鼻窦CT扫描，结合术中鼻内镜准确定位额窦开口，清除或纠正额窦开口及其周围结构病变或变异，以建立良好的符合生理性的额窦通气引流通道。结果：术后随访3～18个月，全部病例症状消失或改善，无一例复发，无术后严重并发症。结论：鼻内镜下额窦手术不失为一种安全、有效及微创的手术方式，适用于大多数额窦病变。     

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis

Objective

To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management.

额窦病变手术径路选择及疗效分析

目的 探讨额窦病变手术径路选择,并分析疗效.方法 回顾性分析28例(30侧)额窦病变,包括额窦炎、额窦囊肿、脓囊肿、骨瘤等,其中17例采用鼻内镜手术,11例采用鼻内镜联合鼻外双径路.结果 术后随访3~12个月,全部病例症状改善或消失,没有出现严重手术并发症.结论 鼻内镜下手术无法完全处理或内镜不能安全达到的额窦后壁或额窦病变部位于超过瞳孔中央假想垂直线外侧的可采取鼻内镜联合额窦前壁开窗双径路手术.术前充分阅读CT,选择适当的手术方式,术中仔细辨认解剖结构,精确定位,可避免严重并发症的发生.术前的综合治疗及术后的定期复查、清理术腔也至关重要.     

Outcomes of frontal mucoceles treated with conventional endoscopic sinus surgery

Conclusion: Conventional endoscopic sinus surgery (CESS) is useful for frontal mucoceles. A patient with short anterior–posterior distance and bone thickening may need an axillary flap, Draf type IIb, or Draf type III procedure. Objective: To present outcomes of frontal mucoceles treated with CESS and predict risk factors for poor outcomes to help define surgical indications. Methods: A consecutive clinical series was reviewed retrospectively. The authors performed CESS without agger nasi resection (Draf type IIa) for 13 frontal sinus mucoceles in 12 patients between October 2011 and July 2013. Patient age, sex, blood eosinophil count, history of operation and co-existence of acute infection were compared. For the condition of the frontal sinus, anterior–posterior distance and width of frontal recess, bone thickening of the frontal recess, bone absorption due to continuous pressure by mucocele and anatomy of the frontal recess was noted. Results: All operations were done without a navigation system. The post-operative course was uneventful in all 12 patients, and all symptoms gradually receded. Among 13 mucoceles, one frontal sinus (7.7%) closed during follow-up.     

The axillary flap approach to the frontal recess

OBJECTIVES: To evaluate the access to the frontal recess using the axillary flap approach by identifying the frontal ostium during endoscopic sinus surgery. STUDY DESIGN: Prospective review of 64 consecutive patients (118 sides) undergoing axillary flap exposure of the frontal recess between November 1998 and July 1999. METHODS: Demographic data, identification of the frontal ostium, findings at surgery, use of nasal packing, the presence of postoperative symptoms, revision surgery, and the endoscopic appearance of the frontal recess were collected. The operative technique is presented. RESULTS: The frontal sinus ostium was identified in 96% of patients (104 of the 118 sides). Eight sides had Kuhn type 3 cells that required removal for clearance of the frontal ostium. Eighty-two percent of sides (97 sides) had endoscopically healed sinuses without symptoms after an average follow-up of 15.4 months. Six sides had middle meatal adhesions requiring division under local anesthetic. One patient has required revision surgery. CONCLUSION: The axillary flap approach to the frontal recess provides excellent access to the frontal recess and allows clearance of cells in the recess with identification of the frontal ostium in the vast majority of cases.     

Endoscopic endonasal transseptal approach for localized sphenoid sinus diseases

Objective

Surgery for localized sphenoid sinus disease can be performed in different ways. Direct (transnasal) and indirect (transethmoidal) approaches are now prevalent in endoscopic endonasal sinus surgery (ESS) because they are safe and effective. However, the identification or treatment of a sinus is occasionally difficult due to the anatomical variation, postoperative changes, or other reasons. In such difficult cases, we currently used an endoscopic endonasal transseptal approach (EETA) to the sphenoid sinus. The indications, procedures, and outcomes of this surgical method are presented here.

Patients and methods

Six of 11 patients with localized sphenoid sinus disease (mycetoma, n = 1; mucocele, n = 5) were treated using EETA. Surgery was performed under local anesthesia in all subjects. Following endoscopic conventional septoplasty, the sphenoid sinus was opened by perforating the anterior wall through the septoplasty wound. The sphenoid disease was treated through this opening, and then drained to the nasal cavity.

Results

The patients operated on using EETA had no surgical complications or disease recurrence, and the use of navigation or fluoroscopy systems was not required. The mean follow-up period of the patients was 27.7 months (range 18–48 months). Follow-up management included endoscopic examination and computed tomography.

Conclusions

A transseptal approach to the sphenoid sinus with a sublabial incision was once frequently performed in pituitary surgery. We modified the transseptal approach as EETA with the use of an endoscope and endonasal incision. This approach is practical and reliable for ESS, and may serve as an alternative for difficult-to-manage sphenoid sinus disease. EETA can be performed in the office as it can be achieved under local anesthesia without a navigation system.     

Frontal sinus complications after frontal craniotomy

OBJECTIVES: To review frontal sinus complications following frontal craniotomy and to describe management strategies. STUDY DESIGN: Retrospective review. METHODS: Retrospective review was made of six patients who had undergone frontal craniotomy and subsequently developed frontal sinus complications. Demographic data, indication for craniotomy, type of reconstruction, average time to development of complications, presenting symptoms, diagnosis, surgical management, follow-up, and outcomes were reported. RESULTS: Complications included unilateral frontal sinus mucoceles in four patients, bilateral frontal sinus mucoceles in one patient, and bilateral frontal sinus mucopyoceles with upper-eyelid abscess in one patient. The average time to presentation of symptoms and development of complications following frontal craniotomy was 14.8 years (range, 1-39 y). Headaches were the most common presenting complaint. All patients underwent endoscopic mucocele marsupialization as part of their management. After an average follow-up period of 9 months, no recurrences were found and no complications occurred. CONCLUSION: A small number of patients develop otolaryngological complications, most commonly, frontal mucoceles, following frontal craniotomy. A high level of suspicion and long-term surveillance are needed to monitor for their occurrence. Endoscopic marsupialization may provide an effective, safe means for management.