Professional Documents
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SINUS
• In a saggital section
frontal recess along
with frontal
infundibulum and
frontal ostium forms
hourglass shaped
structure.
• Thus frontal sinus is
much anterior to frontal
recess when viewed
endoscopically.
CT coronal view sagital view
Normal frontal recess anatomy. Coronal (a) and sagittal (b) CT images show the right
frontal recess (dotted red line), which is bounded anteriorly and laterally by an agger
nasi cell (white arrow) and a type 1 frontal cell (black arrow), medially by the middle
turbinate, and posteriorly by the ethmoid bulla and bulla lamella. The nasofrontal
process (arrowhead in b) forms the floor of the frontal sinus and demarcates the level
of the frontal sinus ostium.
Agger nasi cell
• Type III - Single cell extending from the agger nasi cell into the
frontal sinus
In 1908 Halle chiseled out the frontal process of maxilla and used a
burr to remove the floor of frontal sinus.
In 1914 , Lothrop enlarged the frontal sinus drainage pathway
using intranasal approach.
EXTERNAL APPROACHES –
• Frontal sinus Trephination
• External frontoethmoidectomy
If one needs to achieve a larger drainage opening like type II-b, a drill is used
because of the increasing thickness of the bone medially towards the nasal
septum. At this point microscope assistance is required.
If these frontal cells are present, a procedure known as A large ethmoidal cell (blue)
uncapping the egg is performed resulting in type IIa could be seen extending up
drainage. to the level of frontal sinus.
The frontal sinus could be
After type IIa drainage , further widening to produce a drained only by uncapping
type IIb drainge is done by introducing a diamond burr into this large ethmoidal air cell
the clearly visible gap in the infundibulum which is then (frontal cell). This procedure
drawn across the bone in medial direction. is known as the uncapping
the egg. (Black dotted lines)
During surgery , frontal sinus opening is bordered by bone on all side but mucosa is
preserved on atleast one side.
Rubber finger stall can be introduced into the sinus for 5 days .
They provide safe hemostasis, are a stimulator of re-epithelialization of bare bone, are
cost-effective and painless to remove.
The risk of adhesions and synechiae is low because this type of packing suppresses the
development of granulations.
Leaving rubber finger stalls for one week carries the following advantages –
1. The fibrinoid phase of wound healing is somehow overcome. Reclosure of the large
drainage by scars is remarkably reduced, since bare bone is re-epithelialized almost
completely.
2. Sedation and general anesthesia are not necessary for packing removal. Rubber
finger packs do not bind to the wound.
If previous ethmoidal surgery was If previous ethmoidal surgery was complete, and
incomplete and the middle turbinate the middle turbinate is absent.
is still present as a landmark.
The medial approach starts with the partial
resection of the perpendicular plate of ethmoid
of the nasal septum, followed by identification of
the olfactory fibers on each side.
Post operative Therapy –
The patients are given the following instructions to ensure proper healing:
1. Irrigate the nasal cavities with saline solution at least once a day, sometimes more
frequently.
2. Use one of the corticosteroid sprays 1–3 times/ day.
3. The recommendation is made to use liquid paraffin 1 hour after the use of
corticosteroid spray, for general care of the mucosa.
• Maximum success rate is usually achieved by type III drainage followed by type II
and I .
a)The “chimney” between the anterior ethmoid and the frontal sinus has not been
opened well. It is important that after the anterior ethmoidal artery is identified, the
surgeon proceeds along the skull base medial to the lamina papyracea to enter into
the frontal sinus.
b) The anterior-posterior opening of the frontal sinus floor, particularly in the midline, is
too small. The identification of the first olfactory fiber bilaterally and the creation of
the “Frontal T” are very helpful to avoid this problem.
c) The resection of the septum has been missed or was not performed to a satisfying
degree. The new curved drills between 15° and 60° angle are ideal for this purpose.
d) The resection of the superior nasal septum was too small. The diameter of resection
must be 1.5 cm just in front of the “Frontal T” and below the frontal sinus floor.
e) The packing between the ethmoid and the frontal sinus was not left long enough.
7 days proved to be the best time frame for using rubber finger packings.
Frontal sinus rescue procedures:
This concept has revolutionized frontal sinus surgery, so that the classic
external frontoorbital frontal sinus operations according to Jansen-Ritter or
Lynch or Howarth are considered obsolete for the treatment of chronic
inflammatory diseases of the frontal sinus.
AXILLARY FLAP APPROACH
INDICATIONS-
• Failure of correctly performed type III drainage.
• Type III drainage technically not possible ( AP diameter < 8 mm )
• Laterally located mucopyocoele.
• Major destruction of posterior wall
• Inflammatory complications after trauma (alloplastic material )
• Major benign tumours with and without obliteration( osteoma)
• Problem frontal sinus sometimes in combination with complete endonasal
ethmoidectomy
OSTEOPLASTIC FLAP SURGERY
• Preoperative HRCT and X-ray
occipito-frontal view should be
Supratrochle
done. ar nerve
• From image a contours of frontal
sinus are cut out as a template.
Supra orbital
• A bitemporal coronal incision is artery
Supra orbital
preferred ( invisible scar ) nerve
3. Drill holes
Appearance after down fracturing of anterior wall of
frontal sinus
• 5. preserved fascia
• 6. cartilage
• 7. transplanted fat with
fibrin glue
• 8.fibrin glue
• 9. resorbable sponge
• 10. rubber finger pack
Frontal sinus unobliteration procedure –
Done in cases secondary to trauma or osteom having a healthy frontal sinus
mucosa.
In such cases , decision has to be taken whether the mucosa around the
infundibulum is sufficiently healthy to preserve the frontal sinus or whether
obliteration should be done.
Where sinus is preserved , a type III median drainage is performed from above
and is called as Frontal sinus unobliteration procedure .
Results of osteoplastic flap procedure
Indications –
The initial part of the procedure is same as osteoplastic frontal sinus procedure.
Mucosa of the floor of frontal sinus is completely removed or inverted into the nose.
If small – the connection to the nose is obliterated with conchal cartilage or galeal
periosteal flaps.
Large dead space b/w ant wall and dura – obliterated with abdominal fat , cancelous
bone from iliac crest , hydroxyapatite.
Anterior wall reconstructed with an additional bone graft from temporal area if required.
RHINOFRONTAL SINUS SEPTOSTOMY