Endonasal, microscopically controlled frontal sinus surgery

In the modern age of endoscopic sinus surgery (ESS), there is an undefined role for external approaches in the treatment of inflammatory disease. This study examines the frontal sinus surgery practices of three experienced rhinologists with a focus on those who underwent an external approach. Our goal was to characterize these patients and propose indications for the use of an external approach alone or in combination with functional ESS (FESS) for frontal sinus inflammatory disease. A retrospective review was performed of frontal sinus procedures performed for inflammatory disease at one institution from 2004 to 2007. Seven hundred seventeen procedures were performed, 38 (5.3%) of which were external alone (14 procedures) or in combination with FESS (24 procedures). Osteoplastic flap with obliteration (12/14) made up the majority of external alone procedures and the most common indication was neo-osteogenesis of the frontal recess. Trephination was the most common external adjunct to FESS (12/24), and often was performed for type 3 frontal recess cells or in the initial management of acute frontal bone osteomyelitis (FOM). Twenty-eight of 38 (74%) patients had a history of previous surgery. Of the 10 patients with no history of previous surgery, 6 (60%) had an external adjunct for frontal recess neo-osteogenesis. There were no major complications but 9/38 (23.7%) patients required revision surgery for persistent/recurrent symptoms. External approaches alone and in combination with FESS are predominantly secondary to neo-osteogenesis of the frontal recess. Factors associated with neo-osteogenesis include previous trauma, endoscopic surgery, and FOM. External frontal sinus surgery provides adequate management of inflammatory disease but has a high revision rate.

With continued surgical instrument advancement, endoscopic sinus surgery techniques continue to evolve with an overall improvement of our ability to offer surgical treatment for a variety of surgical disorders of the sinuses and anterior skull base. Frontal sinusitis and the extent of surgery performed in the frontal recess once medical management fails are constantly debated in the literature. It seems that even though instrumentation has greatly improved, surgical management of frontal sinusitis remains a frustrating endeavor for otolaryngologists. Open approaches to the frontal sinus, including the osteoplastic flap with frontal sinus obliteration using adipose tissue, have been the gold standard, but require external incisions and complete removal of sinus mucosa with destruction of the frontal sinus. The endoscopic modified Lothrop technique involves removal of the frontal sinus floor bilaterally with frontal septectomy and resection of the nasal septum to create a large nasofrontal communication. Recent postoperative results of this technique rival the results after frontal sinus obliteration in selected patients while avoiding the morbidity associated with the open destructive approach.

Objective:The aim of this study is to explore the value of 3D reconstruction technology based on computer tomography data in understanding the frontal sinus drainage pathway. Method:Three-dimensional reconstruction of DICOM data from 100 cases of sinus CT was performed by using Mimics 19.0 software. The 3D models were used to study types, the relative locations of frontal sinus and recess cells as well as the influence of the frontal sinus drainage pathway. Result:The 3D model of frontal sinus, frontal recess cells and frontal sinus drainage pathway were reconstructed successfully. Among them, the incidence of nasal cavity was 95.5% (191/200), nasal cavity was 31.5% (63/200), nasal cavity on the frontal air room was 24.5% (49/200) supra bulla cells were 54% (108/200), supra bulla frontal cells were 14.5% (29/200), supraorbital ethmoid cells were 20.5% (41/200), and the rate of frontal septal cells were 4% (8/200). It visually demonstrated the relationship between the frontal recess and the frontal sinus drainage channel. Conclusion:The 3D reconstruction technology based on computer tomography data not only helps us to understand the anatomy of the frontal sinus, the relative position of the frontal crypt and the effect on the frontal sinus drainage channel, but also provides a new method for preoperative planning and intraoperative guidance to endoscopic frontal sinus surgery.

Efficacy of a 5-day course of telithromycin in the treatment of acute maxillary sinusitis caused by drug-resistant Streptococcus pneumoniae

目的 探讨慢性鼻窦炎手术中额窦开口的手术处理原则,以提高慢性鼻窦炎鼻内镜手术的治疗效果.方法经鼻内镜手术治疗慢性鼻窦炎113例(226侧),根据额窦口和额隐窝的不同病变和解剖特征,采用不同的方法处理局部病变.结果术中可见所有病例均有不同程度的中鼻道阻塞.额窦口和额隐窝情况:局部没有气房阻塞,仅有肿胀黏膜、息肉样变黏膜或者息肉阻塞者89侧(39.3%);额隐窝被发育过度的鼻丘气房、筛泡气房或终末气房挤压导致额窦引流通道狭窄者80侧(35.4%);额隐窝完全被发育过度、呈蛋壳样气房阻塞者为36侧(15.9%);额窦自然开口狭窄者21侧(9.4%).额窦内病变情况:积脓、黏膜充血肿胀58侧;黏膜肿胀61侧;黏膜充血90侧,黏膜未见明显病变17侧.随访6～20个月,其中治愈198侧(87.7%),好转21侧(9.29%),无效7侧(3.01%),未见严重手术并发症.结论窦口、鼻道复合体和额隐窝的阻塞是慢性额窦炎的主要原因,额隐窝和额窦口阻塞有4种病变状态,应根据不同的病变采用不同的手术方式。

Long-term results of endoscopic frontal sinus surgery

Endoscopic endonasal anterior skull base surgery is currently applied for the treatment of olfactory neuroblastoma, and other skull base lesions. In the surgical approach to the anterior skull base, one of the important step is extended frontal sinus surgery, including modified endoscopic Lothrop procedure (MELP). Surgical simulation using artificial three dimensional (3D) models is known to a useful training method to learn the surgical steps and to gain the surgical skills. In this study, we investigated the usefulness of a 3D head model with the detailed CT information in the surgical simulation for extended frontal sinus surgeries and anterior skull base resections. 3D head models (KEZLEX, Ohno, Japan) were used as a surgical simulator. This model is exactly reconstructed and made as a human head including sinonasal structure and anterior/posterior skull base by 3D printer. In this model, we made the first olfactory nerve with a steel wire at the skull base as the posterior limit of the frontal sinus flour to the skull base. In addition, the head model was examined for surgical anatomy by using the cone-beam CT (Accuitomo, Morita, Japan). Then, endoscopic endonasal surgery was performed using a high speed bur (M5, Medtronic, Japan) for the bone resection guided with a navigation system (Fusion, Medtronic, Japan). MELP was performed according to the surgical steps of the outside-in frontal drill-out technique. In results, MELP and the anterior skull base resection including crista galli were successfully performed for 3D model with CT and the navigation. These findings suggest that surgical simulation using artificial 3D head model and cone beam CT combined with a navigation system is useful in the surgical training for endoscopic endonasal anterior skull base surgery.

Image-guided sinus surgery (IGSS) is a type of computer-assisted surgical navigation technique. It is also termed computer-aided surgery (CAS) as well as computer-assisted navigation (CAN). Compared to its first description in the 1990s, it is now widely applied by the rhinologists worldwide. While it is not a substitute for surgical expertise or a thorough anatomical knowledge for endoscopic sinus surgery (ESS), it is a valuable aid during any challenging ESS procedure, including surgery for chronic rhinosinusitis, benign sinonasal tumors, CSF rhinorrhea, etc. IGSS is especially helpful in cases of revision ESS, frontal or sphenoid sinus surgery, and ethmoid surgery approaching the ethmoid roof. However, there are also disadvantages including increased cost and increased time in the operating room, particularly early on in the user’s experience as they learn the nuances of system registration. A typical system localizes the tip of a probe, suction, or instrument in three different planes on the patient’s preoperative computed tomographic (CT) images viewed on an attached monitor, while a fourth panel on the screen will frequently contain an endoscopic view. The tip of the instrument is depicted by crosshairs on the abovementioned orthogonal images. Accuracy of the tip localization on the CT images is recognized to be 2 mm or better, thereby providing the surgeon with greater confidence when working in more vulnerable areas such as frontal sinus, optic nerve, base of skull, etc. during ESS. In this chapter, we aim to provide the reader with an understanding of the technology and technique of IGSS and its clinical use in standard and complex cases of ESS.

Can sinus anatomy predict quality of life outcomes and operative times of endoscopic frontal sinus surgery?

BackgroundChronic rhinosinusitis (CRS) is a common disease characterized by inflammation of the paranasal sinuses, with symptoms such as nasal blockage, facial pain, hyposmia, and headache. While these symptoms are often treated as a common cold, the disease can lead to serious complications if left untreated. We present an unusual case of CRS in which the patient presented to the ophthalmology department with persistent pus discharge from the left upper eyelid for 6 months, despite being treated with multiple courses of antibiotics and undergoing incision and drainage procedures.Case presentationA 69-year-old male patient presented with a 6-month history of persistent pus discharge from the left upper eyelid, despite being treated with multiple courses of oral antibiotics and three incision and drainage procedures. He also complained of yellowish nasal discharge and bilateral nasal blockage for the past year but did not seek medical attention for these symptoms. Physical examination revealed pus discharge from the left upper eyelid and widening of the nasomaxillary groove. Nasoendoscopic examination showed bilateral grade 3 nasal polyps with mucopus secretion. CT scan of the paranasal sinuses revealed that the odd presentation was due to the chronic inflammatory process in the paranasal sinuses, which had led to osteitis and hyperostosis. This patient underwent endoscopic sinus surgery (ESS) with left frontal trephination and fat obliteration of the left frontal sinus. The postoperative histopathological report confirmed the diagnosis of benign inflammatory nasal polyp with acute on chronic inflammation. The patient was asymptomatic at 3-month follow-up post-operation.ConclusionOur case report highlights the importance of considering CRS as a possible underlying cause of such unusual presentations, even when the symptoms may appear unrelated. Early diagnosis and treatment of CRS can prevent serious complications and improve patient outcomes. The inflammatory process of CRS leading to osteitis and hyperostosis of the paranasal sinuses complicates the clinical presentation, distorts the usual anatomical structures, and may complicate the operation. CT scan of the paranasal sinus is highly recommended before any sinus surgery. At times, ESS may not be sufficient to eradicate frontal sinus disease. In these cases, an external approach is necessary with or without obliteration of the sinus cavity.

This study evaluates the management of frontal sinus disease using osteoplastic flap surgery (OPFS) in the current era of image-guided endoscopic sinus surgery (IGESS). A retrospective chart review was performed of patients who underwent OPFS and imaged-guided endoscopic frontal sintus surgery in the past 10 years at a tertiary care teaching hospital. Chart reviews of clinic patients and inpatients who underwent OPFS were performed. Indications for surgery, prior sinus surgeries, time to OPFS, post-OPFS sinus surgeries, and associated comorbid factors were reviewed. In the period under review, 710 IGESS cases were performed. Thirty patients, who were candidates for OPFS, underwent IGESS for frontoethmoid disease. Fourteen patients from this group failed IGESS and underwent OPFS. The indications for OPFS included mucocele in 10 cases, tumors in 2 cases, and trauma in 2 cases. Four patients underwent revision OPFS. The patients who failed IGESS had prior trauma, tumor resection, radiation, or large septate frontal sinus with lateral extension in which the mucocele could not be drained endoscopically. The average time to OPFS was 6.2 years (0-27 years). Nine patients had prior sinus surgery (1-7 prior surgeries) and five patients had subsequent endoscopic surgical procedures. In all patients with frontal mucocele, surgery should be attempted endoscopically using IGESS because of the low morbidity of the procedure. Patients with risk factors for failure should be considered for OPFS if IGESS proves to be unsuccessful.

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.

Recurrent or persistent frontal sinus disease after endoscopic sinus surgery poses formidable challenges owing to the frontal sinus outflow tract's complex variable anatomy, close proximity to vital structures, and predilection for scarring and stenosis. Frontal sinus obliteration used to be the preferred technique of most sinus surgeons for addressing difficult frontal sinus disease; however, several effective endoscopic techniques exist as excellent alternative procedures for addressing this difficult clinical problem. Several endoscopic techniques have been described for addressing these problems including endoscopic frontal sinusotomy, the frontal sinus rescue procedure, endoscopic transseptal frontal sinusotomy, and the modified Lothrop procedure. Advances in treating recurrent frontal sinus disease have included recent articles reviewing the long-term outcomes of some of these techniques, the prevalence of frontal sinus cells, the optimization of medical management, and the spectrum of postoperative debridement regimens. When used in the appropriate setting, these less invasive revision endoscopic techniques provide excellent results with low morbidity and several advantages. This article reviews recent developments in the treatment of recurrent or persistent frontal sinus disease including incorporation of these techniques.

Objective To investigate the causes, clinical features, treatment and prognosis of chronic sinusitis and nasal polyps with endoscopic sinus surgery. Methods A total of 10 patients (10 eyes) from clinic of Xi’an No.4 Hospital between January 2001 and December 2016 due to vision loss caused by endoscopic sinus surgery were prospectively examined. All patients were enrolled and administered visual acuity testing, ophthalmic examinations, color photography, and other clinical observations. Results Ten cases of ocular complications occurred, including central retinal artery occlusion in 1 case, optic nerve injury in 6 cases, orbital hemorrhage in 2 cases, and orbital infection in 1 case. Conclusions The complications of endoscopic sinus surgery in patients with chronic rhinosinusitis and nasal polyps are complex, and the preparation, familiarity with nasal endoscopic resection and skilled operation can reduce the occurrence of complications. Timely detection of eye complications can reduce the risk of serious consequences. Visual impairment caused by endoscopic sinus surgery is difficult to treat and result in poor prognosis. Key words: Nasosinusitis; Nasal polyp; Endoscopic surgery; Eye; Complication

Endoscopic sinus surgery has replaced open approaches in many diseases of the frontal sinus. However, in the endoscopic era, the osteoplastic flap (OPF) with and without fat obliteration remains the treatment option for certain frontal sinus pathologies. Few indications remain for this surgical procedure in patients with inflammatory disease of the frontal sinus, such as those cases in which previous endoscopic procedures failed or with pronounced neo-osteogenesis of the frontal recess. Facial trauma resulting in the fracture of the anterior or posterior table of the frontal sinus, or the frontal recess, will require an open approach for reduction and fixation, mainly OPF. The osteoplastic flap without obliteration allows direct access to remove a large osteoma of the frontal sinus, while preserving the function of the frontal sinus, and can be associated, if necessary, with a Draf III approach.KeywordsOsteoplastic flapOsteoplastic flap without obliterationOsteoplastic flap with obliterationFrontal osteoma