David R.

Lobo
Jaime Viera Artiles
Javier A. Ospina
Editors

Atlas of Frontal
Sinus Surgery
A Comprehensive Surgical Guide

123
Atlas of Frontal Sinus Surgery
David R. Lobo  •  Jaime Viera Artiles
Javier A. Ospina
Editors

Atlas of Frontal Sinus Surgery

A Comprehensive Surgical Guide
Editors
David R. Lobo Jaime Viera Artiles
Department of Otolaryngology Department of Otolaryngology
Marqués de Valdecilla University Hospital Marqués de Valdecilla University Hospital
Valdecilla Biomedical Research Institute Research and Innovation Surgery Group-IDIVAL
Santander, Spain Santander, Spain

Javier A. Ospina
Otolaryngology
Fundación Santa Fe de Bogotá
Bogotá D.C., Colombia

ISBN 978-3-030-98127-3    ISBN 978-3-030-98128-0 (eBook)

https://doi.org/10.1007/978-3-030-98128-0

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To my beautiful wife Monica; and my dear sons Juan and Pablo
To my teachers: Drs López-Cortijo, Davies and Ramírez-Camacho
And to my patients with frontal sinus pathology
- David R. Lobo
Foreword

Almost 20 years ago, a passionate and enthusiastic young resident from Spain came to train in
endoscopic sinus surgery with me in Atlanta. Dr. David Lobo’s inquisitive mind, eagerness to
learn, and advanced skills in endoscopic sinus surgery made me think then that he would have
a bright and successful professional journey; he proved me right.
During the progression of his career, and teaching residents and fellows, Dr. Lobo observed
learning challenges and difficulties that most young surgeons face while operating on the fron-
tal sinus. Recognizing the advances made in frontal sinus surgery and the paucity of textbook
publications on the topic, the inspiration for this book was born.
The Atlas of Frontal Sinus Surgery provides a comprehensive step-by-step approach that
helps develop the skills and knowledge to perform safe and successful frontal sinus surgery.
The book is methodically structured to allow for gradual learning of the different surgical
techniques. It is a must-read for young surgeons in training and an outstanding reference for
more experienced clinicians.
Lobo, Artiles, and Ospina recruited a renowned ensemble of international authors with vast
knowledge in the field, who presented their experiences in an easy-to-follow and didactic man-
ner. The chapter on “Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery” is of
distinct significance. Highlighting the importance of posture and comfort will help prevent
surgeons from developing musculoskeletal injuries during surgery, a very prevalent problem in
our specialty.
I am certain that the Atlas of Frontal Sinus Surgery will become a reference book that will
help endoscopic sinus surgeons improve their surgical skills and better understand the nuances
of frontal sinus surgery

Pablo Stolovitzky, MD
Department of Otolaryngology
Emory University
Atlanta, Georgia

vii
Preface

Throughout history, the scientific literature on frontal sinus surgery has reminded us that it is
regarded as one of the most complex and advanced rhinological procedures. It entails working
in a narrow cavity, close to critical structures (e.g., the orbit and the skull base), often using
highly angled optics and instrumentation. There is also a notable risk of complications, of
undesirable scarring that leads to restenosis, and of the persistence or appearance of new
symptoms.
In the case of inflammatory pathology—one of the most frequent indications for frontal
sinus surgery—it is common to encounter a bleeding field where visibility is not optimal, thus
compromising the safety and the expected outcome of the surgery. Medium-term results are
sometimes not satisfactory, due to recurrence of the inflammatory pathology or to stenosis of
the drainage tract of the frontal sinus.
The first endonasal approaches to the frontal sinus were associated with unacceptable mor-
bidity and mortality and were, therefore, largely abandoned in favor of external approaches.
These approaches, which continue to have their indications today, represented the gold stan-
dard of treatment for many years, even though they had a nonnegligible rate of surgical failure
and complications.
The revolution came with endoscopic surgery and the development of endoscopic
approaches to the frontal sinus. The indications have expanded ever since, either to treat the
specific pathology of the frontal sinus or as a preliminary step for other surgical approaches.
These procedures are, therefore, increasingly used despite their complexity.
In developing their technical skills, rhinologists will face cases of different difficulty so that
it is essential to select cases in accordance with their current technical level in order to achieve
an optimal result without exposing the patient to unnecessary risk or incomplete surgery.
In practice, this is not always the case. Failure to achieve the desired result may be because
the most appropriate approach was not selected in a particular case, or because a complete and
meticulous resection of all involved cells was not carried out, resulting in suboptimal exposure
of the frontal recess, which is a frequent cause of failure.
On the other hand, the surgeon may be unduly aggressive in performing the surgery, and if
associated with inexperience, this may put the patient at risk of major complications.
Because of all the above-mentioned complexities, frontal sinus surgery is considered
undoubtedly difficult and requires a long learning curve.
Fortunately, the hard work and effort of many rhinologists throughout history and advances
in recent decades have contributed to making this surgery much safer and more efficient today.
This has been made possible in many ways: through a better understanding both of frontal
sinus pathology and of surgical and radiological anatomy; through the technical advances in
surgical instrumentation and image navigation systems; through the use of mucosal flaps; and
through improvements in preoperative and intraoperative preparation and in postoperative
care.
The aim of the book is to offer readers a guide that will increase their confidence in under-
taking progressively more difficult cases. Moreover, mastering frontal sinus surgery opens up
the possibility of performing complex skull base surgeries in which frontal sinus surgery forms

ix
x Preface

part of the approach and, therefore, this book provides the entire spectrum of current under-
standing of frontal sinus surgery.
The book follows a logical sequence of preparation for surgery, from the simplest and least
invasive procedures for common cases to the most advanced and complex techniques for
unusual and challenging cases. Readers can, of course, choose to consult any specific chapter
or section in search of the relevant information required for a particular case.
The coordination of this book has been immensely interesting, and the whole process has
been a thoroughly enjoyable and enriching experience. It is hoped, therefore, that readers will
derive the same benefits, given that all the authors are proven experts and renowned specialists
with vast experience in this field.
The book is generally addressed to ENT specialists who perform nasosinusal endoscopic
surgery, to rhinologists with experience in this field, and also to those beginning their training.
Nevertheless, it may also be of interest to ophthalmologists, maxillofacial surgeons, and neu-
rosurgeons, since they often work closely with the otolaryngologist, especially if their field of
interest includes endoscopic skull base and/or orbit surgery.
The book covers the full range of frontal sinus surgery, from balloon sinuplasty to extended
frontal sinus procedures. Among many other topics, the book describes complete bone removal
(Draf III), open and combined approaches for craniofacial resection, frontal sinus tumor sur-
gery, open approaches such as osteoplastic flaps with or without frontal sinus obliteration, and
other indications for endoscopic approaches to the frontal sinus such as septal perforation
repair, and large skull base defect reconstruction with pedicle flaps.
The reader should anticipate that this book does NOT aim to provide comprehensive
descriptions of the pathogenesis of diseases affecting the frontal sinus.
The book is structured in a way that allows a gradual learning of the different surgical tech-
niques. It helps both the young surgeon in training and the more experienced practitioner to
progress in endoscopic surgery and to adopt a more complete and safe approach to the frontal
sinus. Given the professional and academic profile of the authors, who have acquired great
experience in this type of surgery, their descriptions and advice will be useful not only for
those who are new to these approaches but also for rhinologists and otolaryngologists with a
special dedication to this subspecialty.
Readers are fortunate to have in their hands a book in which the authors have not only
expressed their deep knowledge and wisdom on this subject, but have done so in a profoundly
educational way, with clear and easy-to-follow explanations. The book is also full of pearls and
technical details that will delight attentive readers.
It conveys the anatomy and detailed steps of each procedure clearly through concise, step-­
by-­step instructions and easy-to-read descriptions of the surgical procedures accompanied by
many illustrations.
One of the hallmarks of the book is that it includes new aspects that reflect recent develop-
ments in the field. It discusses topics that are seen as important and helps to provide optimal
patient care before, during, and after surgery with detailed information on relevant anatomy,
surgical indications, instrumentation, potential pitfalls, and postoperative considerations.
In recent years, there have been great advances in endoscopic sinus surgery but they have
been particularly prominent in frontal sinus surgery with new anatomo-surgical and radiologi-
cal classifications and descriptions of the complexity of the surgery. These have been aided by
advances in such aspects as image processing techniques, surgical instruments, navigation
systems, presurgical checklists, and pre-, intra- and postoperative management, all of which
have greatly improved the safety and results of this complex surgery, which has a potential risk
of major complications. Where relevant, details on all these aspects have been included in the
different chapters of this book.
The book is divided into three parts.
The first part consists of eight chapters that cover all the prior knowledge that a frontal sinus
surgeon must acquire for a solid preparation for safe surgery with the best chance of success.
The chapters deal with novel, lesser known and revolutionary aspects of frontal sinus surgery
Preface xi

that can truly change the way many readers perform frontal sinus surgery. They not only pro-
vide knowledge of surgical anatomy and radiology but also give clear indications on how to
assess the degree of difficulty of a specific surgery.
The knowledge of anatomy acquired from practice on virtual or cadaver models and of
radiological anatomy through the capability of performing reconstructions on three planes or
virtual endoscopies, in which hidden structures (e.g., anterior ethmoidal artery or the skull
base) can be previewed, affords a better understanding both of the frontal sinus in general and
of the particular case to be treated. These eight chapters, as well as a comprehensive coverage
of preparation for surgery, also address key elements for the performance of safe and complete
procedures (training, ergonomics and instrumentation, patient selection, preoperative analy-
ses, indications and contraindications, etc.).
In Chap. 1 Shekhar Rawal introduces the topic and contextualizes frontal sinus surgery in
terms of its importance from different angles including its historical, epidemiological, eco-
nomic, and medicolegal aspects.
In Chap. 2, Gaurav Medikeri, from his extensive experience, provides valuable first-hand
tips and information about training in frontal sinus surgery. While the learning curve usually
begins during a residency program, continuous training is necessary throughout a surgeon’s
career through participation in courses, hands-on workshops, fellowships, etc.
In Chap. 3 Irene Monjas, who along with her neurosurgical team, gives talks all over the
world about skull base 3D anatomy, reviews the surgical anatomy of the frontal sinus in detail.
Readers will be able to build a mental reconstruction of the frontal recess, will understand all
the cells affecting the frontal recess or the frontal sinus itself, and recognize all the anatomical
variations that may pose the greatest difficulty or risk during surgery.
In Chaps. 4 and 6 Claudio Callejas reviews the indications for frontal sinus surgery, and the
recent international classifications for frontal sinus surgery relating to radiological anatomy,
the difficulty of surgery, and the different endoscopic approaches to the frontal sinus (to be
developed in Part II). These chapters are essential, since the international classifications, in
addition to their immense consensus value that allows professionals to understand each other,
play an important educational role by helping to understand this complex anatomy, the differ-
ent approaches, and the range of difficulties involved in every frontal sinus surgical
intervention.
Presurgical preparation is essential to obtain optimal results and Yvonne Chan and Alkis
Psaltis enlighten us about the best management based on the most recent literature and their
own experience in Chap. 5.
Serafín Sánchez, who contributes Chap. 7, has for many years run an international course
on preoperative analysis of endoscopic sinus surgery and has a wealth of experience in preop-
erative image analysis, 3D reconstruction, and surgical planning, which is reflected in this
marvelous chapter.
Ergonomics is addressed in Chap. 8. Endoscopic sinus surgery (ESS) has been associated
with physical discomfort and musculoskeletal disorders. This might be related to poor ergo-
nomics within the operating room (OR) environment, but also to the strong demands that this
procedure imposes upon the surgeon. The incidence of cervicobrachial disorders in surgeons
who perform minimally invasive procedures is high. Recognition of this problem has resulted
in the creation of new equipment, improvements in the design and distribution of the OR as
well as greater postural awareness. The chapter is essential for a long and healthy career in this
field. Additionally, ergonomic improvements in the OR contribute to the safety and efficiency
of surgical procedures, and result in greater comfort for the surgeon and better results for the
patient.
The 20 chapters of Part II take the reader through the different surgical techniques, from
balloon sinuplasty, through all Draf approaches and the more recently described Eloy
approaches, to open techniques, together with their application to the resolution of specific
frontal sinus pathology such as osteoma, inverted papilloma, mucocele, fracture, etc., which
have their singularities. Also described are different surgical procedures in which frontal sinus
xii Preface

surgery is a necessary prior step, such as the closure of cerebrospinal fluid leaks, closure of
septal perforations, resection of skull base tumors, etc. These chapters are covered by several
of the world’s foremost rhinologists and most renowned and recognized leaders in sinus
surgery.
The detailed description of the surgical procedure is supported, where possible, with clear
schemata or drawings, and high-quality illustrative video clips. Illustrations and short video
clips will serve to clarify different aspects of surgical technique. The authors’ extensive experi-
ence will make even the tiniest details invaluable.
Sinus balloon sinuplasty is a fairly new technique, approved by the United States Food and
Drug Administration (FDA) in 2005. Increasingly, balloon sinuplasty is being recognized and
fully covered by medical insurance companies. A 2017 study found that the number of balloon
sinus procedures performed in the U.S. increased 59 percent annually from 2011 to 2014. A
whole chapter devoted to this topic is well justified and is, therefore, comprehensively covered
in Chap. 9, which describes the evidence-based medicine, possible controversies, and pitfalls
of sinus balloon sinuplasty.
Finally, the five chapters of Part III cover frontal sinus surgery complications, postoperative
management, debates and controversies concerning frontal sinus surgery, and the future of
frontal sinus surgery.
Stephen Ball and Richard Douglas, in Chap. 29, address frontal sinus surgery complications
and how to identify and manage them, while Maite Pinilla and Beatriz Arellano discuss in
Chap. 30 the management of orbital and central nervous system (CNS) complications of fron-
tal sinusitis. They provide magnificent chapters on this topic.
Postoperative care is essential to achieve the best results and Yvonne Chan and Alkis Psaltis
summarize in Chap. 31 a number of postoperative strategies that can be employed to enhance
wound healing of the sinonasal mucosa after successful sinus surgery.
In an excellent Chap. 32, Mark Arnold and John DelGaudio offer us an impressive overview
of what constitute the challenges and the most controversial aspects of frontal sinus surgery
today. Undoubtedly, it is an inspiring chapter for all those who with their work and effort are
providing ever increasing evidence of the best therapeutic approaches to frontal sinus diseases
or offering new therapeutic solutions for these diseases.
This book aims to provide a highly practical and useful guide to frontal sinus surgery, but it
is also hoped that it might also prove inspiring by dealing with the most recent advances in the
field. In this regard, the final chapter covers the most recent advances in frontal sinus physio-
pathology and new treatments with biologic drugs that may revolutionize sinus therapy in the
near future.
This Atlas gets right to the point, to the heart of the matter, which is to build surgeon skills,
references, and knowledge for a complete and safe frontal sinus surgical procedure. We really
believe that the book can help many colleagues to better understand and perform frontal sinus
surgery. It aims to help surgeons develop new skills step by step and to make steady progress
in their surgical expertise.
If this book helps a colleague to improve his or her surgical results, to progress safely, and
to have the confidence and skills to face cases of increasing difficulty, it will have been worth
the effort.

Santander, Spain David R. Lobo

Santander, Spain  Jaime Viera Artiles
Bogotá D.C., Colombia  Javier A. Ospina
Acknowledgments

This book would not have seen the light of day without the invaluable contribution and help of
many people who made it possible through their efforts and support.
First of all, I would like to thank the coeditors of this work, Javier Ospina and Jaime Viera,
for their support throughout this long process, and especially for their availability and dedica-
tion. They have worked with passion and enthusiasm on this project.
Secondly, I would like to convey my genuine appreciation to all of the authors. In the midst
of this long pandemic, with all their professional commitments, they have given all their heart
and wisdom to this project. Thanks to their excellent contributions, this Atlas aspires to become
the benchmark, the bedside book of frontal sinus surgery for colleagues around the world. The
authors were always available and generously responded to all of our comments and
suggestions.
In particular, I would like to thank Claudio Callejas for the trust and support he has given.
He immediately became enthusiastic about the project. He infused us with his enthusiasm and
actively participated in the conception and structure of the book.
I am also very honored by the contribution of José Luis Llorente, director of a fellowship in
skull base surgery for many years and my teacher, who remains very close despite his invari-
ably busy schedule. My sincere thanks for supporting all the initiatives and projects that we
undertake. I will remain forever indebted to him for his teaching, mentoring, and friendship.
My gratitude to the Marques de Valdecilla Hospital, to my colleagues in the ENT Department
and in the Rhinology and Skull Base Department, for giving me the opportunity to work in a
magnificent team and a magnificent environment capable of providing our patients with the
highest quality care.
I would like to thank Nacho del Moral and José Maestre for all the conversations we have
had, always enriching and inspiring, and the rest of the workers of the Valdecilla Virtual
Hospital, where our endoscopic sinus surgery courses are held, for their kindness and
professionalism.
My thanks to Dr Francisco Galo, Ana Temperán, Marina Calvo, and colleagues from the
IDIVAL Innovation Support Unit for their promotion of ergonomics and human factor studies
of health technologies and processes, and for supporting their implementation in order to make
their use safer.
My thanks also to all my colleagues and trainees that make rhinology an exciting and satis-
fying field.
In addition, I would like to thank the Spanish Society for Otolaryngology Head and Neck
Surgery members for their ongoing support of the development of academic ENT.
Special thanks go to Dr Pablo Stolovitzky, who has generously accepted my invitation to
write the foreword to this book. He is an experienced healthcare leader skilled in innovative
approaches to Physicians' Practice Management, Medical Education, and Clinical Research in
the field of otolaryngology at national and international levels. I will always be grateful to him
for opening doors for me almost 20 years ago in Atlanta, during my training as a resident. I was
fortunate to learn with a person who is so passionate and committed to our specialty. Not only
did he help cement my interest in endoscopic surgery and rhinology, but also inspired me with
his energy, positivity, and humanity.

xiii
xiv Acknowledgments

I would like to express my gratitude to Springer Nature, who from the first moment agreed
to edit this book and provided their support and cooperation for this work to achieve a high
quality of editing, images, and multimedia. My thanks, too, for promoting and publicizing the
book so that it can reach the widest possible audience among professionals interested in this
subject.
Last but not least, my deepest thanks to my wife and my children for patiently enduring my
work, despite the hours it has stolen from them.
Contents

Part I Preparations

1 An
 Overview of Frontal Sinus Surgery. Past, Present and Future�������������������������   3
Chandrashekhar Rawal and Patricia Corriols
2 Training
 in Frontal Sinus Surgery ���������������������������������������������������������������������������  15
Gaurav Medikeri
3 Frontal
 Sinus Classical and Endoscopic Anatomy���������������������������������������������������  21
Irene Monjas Cánovas and Elena García Garrigós
4 Indications
 of Frontal Sinus Surgery �����������������������������������������������������������������������  37
Claudia González and Claudio Callejas
5 Pre-operative Medical Management�������������������������������������������������������������������������  59
Yvonne Chan and Alkis J. Psatis
6 Classification
 of the Frontal Sinus Anatomy, the Extent,
and Complexity of the Frontal Sinus Endoscopic Surgery�������������������������������������  65
Claudio Callejas and Claudia González
7 Surgical
 Planning: Three-Dimensional Imaging, Stereolithography,
and Virtual Surgery ���������������������������������������������������������������������������������������������������  85
Serafín Sánchez-Gómez, Ramón Moreno-Luna, Juan Manuel Maza-Solano,
Jaime González-García, and Jesús Ambrosiani Fernández
8 Ergonomic
 Aspects and Instrumentation in Frontal Sinus Surgery ��������������������� 113
David Lobo, Jaime Viera-Artiles, Juan Maza, and Roberto Megía

Part II Step by Step Procedures

9 Frontal
 Balloon Sinuplasty: Frontal Sinus Surgery
Without Tissue Removal��������������������������������������������������������������������������������������������� 131
Guillermo Plaza, Peter Baptista, and Elgan Davies
10 Cells
 Removal: Draf Type I and IIA������������������������������������������������������������������������� 141
Jaime Viera-Artiles, Roberto Megía, and David Lobo
11 The
 Vertical Bar Concept in Frontal Recess
and Frontal Sinus Surgery����������������������������������������������������������������������������������������� 149
Gustavo Coy, Flavia R. Demarco, Camila S. Dassi, João Mangussi-Gomes,
and Aldo C. Stamm
12 Bone
 Removal. Grade 4-5: Partial Removal of Frontal Sinus
Floor. Draf II B����������������������������������������������������������������������������������������������������������� 157
Humbert Massegur, Juan Ramon Gras-Cabrerizo, and Juan Manuel Ademà

xv
xvi Contents

13 Bone
 Removal Grade 5 (Complete Removal of Unilateral
Frontal Sinus Floor) Including Eloy IIC, IID, IIE, IIF������������������������������������������� 165
Christina H. Fang, Ariel Omiunu, Jordon G. Grube,
and Jean Anderson Eloy
14 Bone
 Removal. Grade 6: Draf III ����������������������������������������������������������������������������� 171
Alfredo García-Fernández, Nieves Mata-Castro,
and Esther García-González
15 Frontal
 Sinus Surgery (Draf III) as a Previous Step to a more
Complex Technique Part 1����������������������������������������������������������������������������������������� 177
Juan Carlos Ceballos Cantu, Isam Alobid Alobid,
and Cristóbal Langdon Montero
16 Frontal
 Sinus Surgery (Draf III) as a Previous Step to More
Complex Techniques Part 2��������������������������������������������������������������������������������������� 183
Alfonso Santamaría-Gadea, Cristóbal Langdon, and Isam Alobid
17 External
 Approaches to the Frontal Sinus. Osteoplastic Flaps
With or Without Frontal Sinus Obliteration����������������������������������������������������������� 191
Daniel Pedregal, David Lobo, Jose Luis Llorente,
and Roberto Megía
18 Indication
 of Frontal Sinus Trephination Procedure����������������������������������������������� 201
Roberto Megía, David Lobo, and Jaime Viera
19 The
 Place of Riedel–Mosher’s Procedure in Contemporary
Sinus Surgery ������������������������������������������������������������������������������������������������������������� 207
Giacomo Pietrobon, Francesco Bandi, Andrea Preti, Paolo Castelnuovo,
and Apostolos Karligkiotis
20 The
 Importance of Frontal Sinus Surgery in Craniofacial Resection.
Endoscopic, Open, and Combined Approaches������������������������������������������������������� 217
José Luis Llorente, Fernando López, María Costales,
Patricia García-Cabo, and Carlos Suarez
21 Frontal Sinus Tumours����������������������������������������������������������������������������������������������� 225
Cristóbal Langdon and Claudio Arancibia
22 Transorbital
 Approach to the Frontal Sinus������������������������������������������������������������ 231
Giacomo Sollini, Matteo Zoli, Stefano Ratti,
Lucia Manzoli, Diego Mazzatenta, and Ernesto Pasquini
23 Revision
 Surgery of the Frontal Sinus ��������������������������������������������������������������������� 237
Javier Ospina and Arif Janjua
24 Treatment
 of Frontal Sinus Trauma and CSF Leaks ��������������������������������������������� 247
Sara Zaldívar Saiz-Maza, Alfonso Santamaría-Gadea,
and Franklin Mariño-Sánchez
25 Treatment
 of Frontal Sinus Mucoceles��������������������������������������������������������������������� 263
Gonzalo Díaz Tapia, Fernando González Galán, Alvaro Sánchez Barrueco,
Jessica Mireya Santillán Coello, and José Miguel Villacampa Aubá
26 Treatment
 of Frontal Sinus Osteomas����������������������������������������������������������������������� 269
Erin Reilly and Roy Casiano
27 Treatment
 of Frontal Sinus Inverted Papilloma ����������������������������������������������������� 277
Luis Macias-Valle
28 Mucosal
 Flaps in Frontal Sinus Surgery������������������������������������������������������������������ 281
Juan Carlos Ceballos Cantu, Cristóbal Langdon, and Isam Alobid
Contents xvii

Part III Complications, Postoperative Management, and Open Issues

29 Complications
 of Frontal Sinus Surgery������������������������������������������������������������������� 287
Stephen Ball and Richard Douglas
30 Management
 of Orbital and CNS Complications of Frontal Sinusitis ����������������� 295
Beatriz Arellano Rodríguez and Mayte Pinilla Urraca
31 Postoperative Management��������������������������������������������������������������������������������������� 301
Yvonne Chan and Alkis J. Psatis
32 Debates
 and Controversies in Frontal Sinus Surgery��������������������������������������������� 311
Mark Arnold and John M. DelGaudio
33 Future
 of Frontal Sinus Surgery: Beyond Surgical Treatment������������������������������� 317
Ramón Moreno-Luna, Ainhoa García-Lliberós de Miguel,
Serafín Sánchez-Gómez, and Alfonso del Cuvillo Bernal
 Part I
Preparations
 An Overview of Frontal Sinus
Surgery. Past, Present and Future 1
Chandrashekhar Rawal and Patricia Corriols

1.1 Historical Perspective revolutionized frontal sinus surgery and has become the
standard approach to frontal sinus disease [12, 13].
The ideal treatment for frontal sinus diseases should provide Frontal sinus surgery, the most challenging paranasal
complete relief from the symptoms, preserve the function of sinus surgery, requires meticulous preoperative planning to
the sinus, and cause the least morbidity and cosmetic defor- prevent any complications. Contemporary instrumentation,
mity possible. Over the last two centuries a variety of surgi- stereotactic navigation, and the development of new implant-
cal procedures have been described to manage frontal sinus able devices have contributed to improve patient care. The
disease and prevent potentially life-threatening remarkable dissecting capabilities of powered instrumenta-
complications. tion, integral to some approaches to the frontal sinus, need
Runge is considered a pioneer in performing an oblitera- careful handling by experienced and inexperienced surgeons
tion procedure of the frontal sinus in 1750 [1]. In 1870, Wells alike [14]. Over the last four decades, with the advancement
described an external and intranasal drainage procedure for a of endoscopic sinus surgery, combined with our understand-
frontal sinus mucocele [2]. Ogston first described modern ing of the importance of mucosal preservation, frontal sinus
trephination of the frontal sinus in 1884 and shortly thereaf- surgical procedures have moved away from external
ter, in 1896, Luc described a similar procedure. It consisted approaches in the management of inflammatory sinus dis-
of an external approach to the frontal sinus in which he per- ease [15].
formed a trephine through the anterior table, creating a drain- Open approaches remain relevant in situations of difficult
age pathway into the nose through the anterior ethmoid [3]. disease or as part of combined approaches (Fig.  1.1).
Frontal sinus surgery procedures evolved from trephina- Endoscopic surgery, however, is central to the contemporary
tion (1750), to radical ablation procedures (1895), and surgical management of frontal sinus disease [16].
slightly more conservative procedures (1905). Accordingly, many different endoscopic techniques for
At the beginning of the twentieth century, fronto-­ approaching the frontal sinus have been developed, from the
ethmoidectomy followed by introduction of osteoplastic procedures described by Draf to the more recent ones
anterior wall approach to the frontal sinus was described described by Eloy, which will be addressed in other chapters
(Jansen 1893; Schonborn and Brieger 1894, 1895; Winkler of the book.
and Beck 1904, 1908; Beugara and Itoiz 1934; Montogomery
1958) [4, 5], Table 1.1.
In the second half of the twentieth century, Messerklinger, 1.2 Definition of Frontal Sinus Surgery
Wigand, Stammberger, Kennedy, and other pioneers and Main Indications
contributed to spread endoscopic sinus surgery throughout
the world. Recently, endoscopic intranasal approach has 1.2.1 Definition

C. Rawal (*) The main goal of frontal sinus surgery is to eradicate disease,
Head of Department of Otolaryngology-Head and Neck Surgery, preserve function, and maintain external appearance. Two
Tree Top Hospital, Malé, Republic of Maldives broad categories of surgical techniques have been described.
e-mail: [email protected] The first category of techniques is aimed at reestablishing a
P. Corriols path for drainage and ventilation of the frontal sinus cavities.
Department of Otolaryngology-Head and Neck Surgery, Hospital Although these are mainly endoscopic, there are still indica-
Universitario Marqués de Valdecilla, Universidad de Cantabria,
Santander, Spain tions for some external permeabilization techniques. Sinus

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 3

D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_1
4 C. Rawal and P. Corriols

Table 1.1  Historical perspective of sinus surgery

S. No Surgeon Year Procedure
1. Runge [1] 1750 Trephination and obliteration techniques
2. Wells [2] 1870 External and intranasal drainage procedure for a frontal
sinus mucocele
3. Ogston [3] 1884 Trephination procedure through the anterior table
4. Jansen [6] 1893 Osteoperiosteal flap
5. Kuhnt [5] 1895 Removal of anterior wall of frontal sinus
6. Riedel/Schenke [5] 1898 Obliteration of the frontal sinus by completely removing
the anterior table and the floor of the frontal sinus
7. Killian [7] 1903 Modification of the Riedel–Schenke procedure
8. Knapp [8, 9] 1908 Ethmoidectomy via medial wall and entering the frontal
sinus through its floor
9 Lynch [10] 1921 Fronto-ethmoidectomy
10. Goodale and Montgomery [11] 1958 Popularized osteoplastic flap in the USA
11. Messerkilnger, Wigand, Stammberger, 1970 Endoscopic sinus surgery
Kenedy [12]

a b

Fig. 1.1 (a) Endoscopic view of right frontal sinus mucormycosis. (b) Combined approach (external and endoscopic) for surgical management of
frontal sinus mucormycosis. (Source: Courtesy of Dr. Shashikant Mhashal Professor Cooper Hospital, Mumbai)

exclusion techniques should be reserved for failure or unfa- 1.2.2 Indications

vorable cases due to very complex anatomy or pathology. In
these procedures, the entire sinus mucosa is resected, the The indications of frontal sinus surgery include acute and
sinus is filled, and any nasofrontal communication is chronic infectious and inflammatory diseases, benign and
obliterated. malignant tumors, anterior skull base defects, or trauma
The frontal sinus is undoubtedly a great challenge; not leading to cerebrospinal fluid leak or iatrogenic injuries to
only because of the complex anatomy of its drainage path- the frontal sinus (Figs. 1.1, 1.2, 1.3, 1.4, and 1.5).
way, or because of the proximity of vital structures that can Recurrent acute frontal sinusitis (AFS) is defined as AFS
complicate dissection at this level, but also because of the that recurs at least 3–4 times per year. An urgent or emergent
difficulty of obtaining satisfactory functional results surgical treatment for AFS is undertaken when the infection
consistently. fails to respond to maximal medical therapy or when orbital
1  An Overview of Frontal Sinus Surgery. Past, Present and Future 5

a b

Fig. 1.2 (a) External appearance of frontal sinonasal mucormycosis, with orbital bulge. (b) Coronal T2 weighted of magnetic resonance imaging
(MRI) demonstrating orbital invasion. (Source: Courtesy of Dr. Samir Bhagava, Hon.Prof. Cooper Hospital, Mumbai)

Chronic frontal sinusitis (CRS) with or without polyps is

a common indication for frontal sinus surgery, particularly
when symptoms are not well controlled by maximal or
appropriate medical therapy [17].
Prior endoscopic sinus surgery in the anterior ethmoidal
area, or previous surgical procedures at the level of the fron-
tal recess, can cause neo-osteogenesis in the frontonasal
duct, hindering frontal sinus drainage. Thus, iatrogenic
affection of the frontal sinus is a common indication for fron-
tal sinus surgery (Figs. 1.4 and 1.5).
Less frequent indications for frontal sinus surgery include
anatomic and structural features interfering with frontal
sinus outflow tract, frontal sinus fractures, mucoceles, benign
tumors (osteoma, inverted papilloma), and frontal sinus
malignancies.
Anatomical defects in the anterior skull base (congenital,
traumatic, or iatrogenic) can be associated with the presence
of cerebrospinal fluid leak or with the presence of meningo-
encephaloceles. These conditions, although infrequent, are
Fig. 1.3  Axial view of computed tomography showing frontoeth- clear indications for frontal sinus surgery.
moidal sinus occupation and bone destruction at right lamina papyracea Indications for frontal sinus surgery raise two issues: the
with proptosis of right eye due to sinonasal mucormycosis. (Source: need for surgery and the selection of the appropriate proce-
Courtesy of Dr. Shashikant Mhashal Professor Cooper Hospital,
Mumbai) dure. When making these decisions, it is necessary to take
into account the medical therapies used and previous surgi-
cal intervention attempts [18].
or intracranial complications are suspected. Invasive fungal The main indications are summarized in Table 1.2.
frontal sinusitis or aspergillomas are also an indication for The indications for operative management of frontal sinus
surgery, due to their aggressiveness and refractoriness to surgery in children are similar to those in adults, although
medical treatment [17] (Figs. 1.2 and 1.3). some conditions such as AFS or CRS are less frequent in
6 C. Rawal and P. Corriols

a b

Fig. 1.4 (a, b) Magnetic imaging resonance (MRI)T2 sequence in axial view showing a left frontal sinus mucocele, closely related to left orbit

children, due to their underdeveloped frontal sinuses. Frontal significant disease burden, affecting about 11% of the popu-
sinus fractures, complications of frontal sinusitis (most com- lation worldwide [20]. In Europe and the USA, the preva-
mon in older children), refractory frontal sinusitis, disease lence of CRS is variously estimated at 10% to 12% [19].
spread anteriorly into the frontal bone subperiosteal space Most forms of CRS fall into one of the two categories:
(Pott’s puffy tumor), disease spread posteriorly into the epi- chronic rhinosinusitis with nasal polyps (CRSwNP) and
dural or subdural space, or frontal sinus tumors are clear chronic rhinosinusitis without nasal polyps (CRSsNP).
indications for frontal sinus surgery in children. CRSwNP is defined as CRS with identification of nasal pol-
yps and may be diagnosed reliably by means of nasal endos-
copy and/or imaging techniques [21–23]. Both subtypes can
1.3 Epidemiology affect frontal sinuses, typically when polyps and inflamma-
tion are located within the anterior ethmoidal cells, and the
Every year, rhinosinusitis affects an estimated 30 million frontonasal duct is blocked, hampering frontal sinus
people in the USA, which results in four million visits to drainage.
physician offices per year [19]. It has female predilection, The incidence of CRSwNP varies between regions and
and the highest incidence is between the ages of 45 and countries. In Europe, the incidence was estimated to be about
64 years. 40% in the early 1990s and 2–4% in the late 1990s and the
Acute frontal sinusitis is considerably less common than early twentieth century, according to different studies [24–
sinusitis of the maxillary and ethmoid sinuses. Frontal sinus 27]. In North America, the incidence of CRSwNP was esti-
involvement is most common in adolescent boys and young mated to be about 4% in 1997 according to Settipane [28].
men, presumably due to peak vascularization and develop- Newton et  al. estimated the incidence in the rest of the
ment, which occurs between the ages 7 and 20; the reason for world to be 4% in 2008 [29].
the apparent gender predilection remains unclear. Few studies have looked into the prevalence of frontal
Chronic rhinosinusitis (CRS) is defined as inflammation cells, and fewer still have investigated the relationship
of the sinonasal tract lasting more than 12 weeks. CRS has a between frontal cells and frontal sinus disease. Some studies
1  An Overview of Frontal Sinus Surgery. Past, Present and Future 7

chronic rhinosinusitis is not significantly different from the

prevalence in a normal population [30]. Nevertheless, other
studies suggest that the presence of suprabullar frontal and
supraorbital ethmoid cells has a significant association with
the development of frontal sinusitis [31–33].
In addition to the prevalence of CRS (which includes
frontal sinus involvement to a greater or lesser extent), the
prevalence of other frontal sinus pathologies will be briefly
discussed.
Allergic fungal sinusitis is a noninvasive form of fungal
rhinosinusitis. There is great geographical variation in the
incidence of cases, with a higher incidence in regions of rela-
tively high humidity and temperature conditions. Allergic
fungal sinusitis has no gender predilection and is most com-
mon in young adults.
Allphin described an incidence of 1.7% in Cleveland
(Ohio) between 1985 and 1990, closely similar to the inci-
dence described by Ramadan in Morgantown (Virginia) of
1.4% between 1991 and 1995 [34, 35]. Higher rates (8.2%)
were detected in Bombay (India) by Deshpande [28], and
also in the studies performed by Ence in San Antonio, Texas
(6.8%), and Katzenstein in St. Louis, Missouri (6.2%) in the
1980s and 1990s of the past century [36, 37].
Frontal sinus trauma is not rare and represents 8% of the
facial fractures. Most frontal sinuses injuries are related to
automobile accidents, physical aggressions, fire arm wounds,
and civil construction accidents. Regarding the type of frac-
ture, the most common is the anterior table of the frontal
sinus, although the most serious cases also involve the poste-
Fig. 1.5  T2 sequence MRI in frontal view showing a left frontal sinus
mucocele rior table and/or the floor of the sinus, the nasofrontal duct
may be involved. A controversial aspect in these fractures is
Table 1.2  General classification of sinus diseases and its conditions nasofrontal duct management and the possibility of compli-
Infectious diseases Recurrent or refractory acute frontal cations when it is damaged, such as sinusitis and frontal
sinusitis sinus mucocele; not all cases undergo surgery, especially
Orbital or intracranial complications of those with isolated frontal table fracture [38].
AFR
Fungal sinusitis—Frontal aspergilloma
Mucormycosis
Inflammatory Chronic rhinosinusitis with or without 1.3.1 Pediatric Population
conditions polyps
Allergic fungal rhinosinusitis About 5% to 13% of childhood viral upper respiratory tract
Mucoceles
infections may result in acute rhinosinusitis [39–45], some
Barotrauma
Benign tumor Symptomatic or large osteomas of them develop chronic conditions.
Inverted papilloma Pediatric CRS may co-occur and/or may be aggravated by
Malignant tumor other ubiquitous conditions such as allergic rhinitis and ade-
Anterior skull base Frontal sinus fractures, cribriform lamina noid disease [25, 46, 47]. A study conducted by Settipane
defects defects documented that 0.1% of the children and 20% of the patients
Meningoencephaloceles
suffering from mucoviscidosis suffer from CRS [48].
Iatrogenic previous Frontal recess neo-osteogenesis
FESS Stenosis of frontonasal duct Although it is less common than acute rhinosinusitis,
CRS is becoming more frequent and significantly affects the
quality of life in children and can substantially impair daily
have shown no relation between the presence of frontal cells function.
and the development of frontal sinusitis, and it is likely that Frontal sinus disease in children is self-limiting because
the prevalence of the various frontal cells in patients with of the ongoing development of frontal sinus. If the disease
8 C. Rawal and P. Corriols

does not respond to medical treatment, surgical frontal cases of allergic fungal rhinosinusitis, patients have IgE-­
decompression is mandatory. Other factors must be consid- mediated allergy to fungi.
ered in refractary frontal rhinosinusitis such as asthma, cys- • Aspirin-exacerbated respiratory disease (AERD): The
tic fibrosis, and less likely various immunodeficiency combination of asthma, CRS with nasal polyposis, and
diseases (mainly involving IgG subclass), chemotherapy, aspirin sensitivity is called aspirin-exacerbated respiratory
AIDS, failed appropriate allergy management, etc. [29, disease. These three disorders are believed to be linked by
49–54]. an underlying biochemical abnormality in airway tissues,
namely overproduction of cysteinyl leukotrienes.
• Eosinophilic granulomatosis with polyangiitis (EGPA,
1.3.2 Frontal Sinusitis Complications formerly: Churg-Strauss Syndrome) and granulomatosis
in Children with polyangiitis (GPA, formerly Wegener Syndrome).
CRS may be the presenting feature of an underlying sys-
The prevalence of sinogenic intracranial complications in temic vasculitic syndrome [59]. Nasal polyps are associ-
children has not been extensively studied. A retrospective ated with EGPA, whereas bony destruction and septal
study conducted at Stollery Children’s Hospital in Edmonton, erosion are much more commonly associated with
Alberta, Canada examined the prevalence of intracranial GPA. More rarely, sarcoidosis may present with CRS.
complications in pediatric frontal sinusitis: 62.9% required • Viral infections: In a small number of cases, patients
surgical therapy for the disease and about 11.4% had intra- appear to develop frontal CRS after a period of repeated
cranial complications [54]. exposure to viral upper respiratory infections [60].
Intracranial extension from the frontal sinus can occur by • Sinonasal anatomic variations: Certain anatomic variants,
direct extension via a bony dehiscence or more commonly such as septal deviation, concha bullosa, or a displaced
by retrograde thrombophlebitis through valveless diploic uncinate process, can predispose to obstruction of the
pathways (veins of Breschet) in the posterior table of the frontal osteomeatal unit. However, there is little evidence
frontal sinus. Adolescents have been shown to be at highest that these play a role in most cases of CRS [61].
risk for the development of intracranial complications of • Smoking and exposure to tobacco: Active cigarette smok-
frontal rhinosinusitis. This is thought to result from the ing is an important risk factor for CRS [61].
combination of frontal sinus size and high diploic vascular- • Occupational and environmental factors: Sustained expo-
ity, permitting greater communication between these two sure to environmental noxious or ciliostatic substances,
spaces [55]. such as formaldehyde, may also contribute to nasal and
Germiller et  al. reviewed the presentation and manage- sinus mucosal inflammation and decreased mucociliary
ment at their hospital of children with intracranial complica- function, thereby predisposing to sinus infection.
tions arising from frontal rhinosinusitis between 1900 and • Depression: In a systemic review, the prevalence of pos-
2000. Subdural (56%), epidural (44%), and cerebral sible or likely depression was 11–40% among patients
abscesses (19%) were the most common complications seen with CRS.  Patients with both depression and CRS
in 16 pediatric patients [56]. improved with treatment but did not attain the same
degree of improvement in quality of life as those without
depression.
1.4 Risk Factors for Frontal Sinus Disease • Immunosuppressed patients: Defective or deficient anti-
body production is found in some children and adults
The following conditions predispose to frontal sinus with CRS.  The specific disorders associated with CRS
disease: include various forms of hypogammaglobulinemia and
specific antibody deficiencies. Most patients with defec-
• Asthma: Approximately 20% of patients with CRS have tive or deficient antibody production have a pattern of
concomitant asthma, and two-thirds of patients with recurrent acute episodes of purulent infection [62].
asthma, including both children and adults, have evidence • Previous endoscopic sinus surgery: Prior endoscopic
of chronic sinus mucosal thickening or sinus opacification sinus surgery in the anterior ethmoidal area or previous
in cross-sectional studies [57]. CRS with nasal polyposis surgical procedures at the frontal recess are related to neo-­
is much more strongly associated with asthma than CRS osteogenesis or disturbance in the normal frontal sinus
without nasal polyposis. drainage, especially when there is no preservation of the
• Atopy/allergic rhinitis: Among CRS patients undergoing mucosa.
sinus surgery, the prevalence of positive skin prick tests • Helicobacter pylori and gastro-esophageal reflux (GERD).
ranges from 50% to 84%, of which the majority of patients There are few studies and its relationship with frontal
(60%) have multiple sensitivities [58]. By definition, in sinusitis is not clear.
1  An Overview of Frontal Sinus Surgery. Past, Present and Future 9

1.5 Socioeconomic Importance all money transferred, meaning the actual reimbursement
from the payers to the hospital, the surgeon, and the anesthe-
1.5.1 Socio-Economic Impact of Frontal Sinus sia department for the 100 patients in the cohort [68]. The
Disease total surgical costs reached $6490 as the sum of hospital
($3072 ± $1237), surgeon ($2869 ± $2180), and anesthesi-
Chronic sinusitis is the second most common chronic condi- ologist reimbursements ($549 ± $262) [77, 78].
tion after hypertension. The economic impact of CRS can be In recent decades, the number of endoscopic surgical pro-
described at both the societal level and the individual level. cedures performed on the frontal sinus and the associated
Frontal sinus disease can have a negative impact on patients’ costs have increased considerably. In a recent study, the addi-
quality of life. Various studies have demonstrated that CRS tion of frontal sinusotomy for patients with CRSwNP was
has a much greater impact on patients’ quality of life than not found to be cost-effective at a willingness to pay (WTP)
other chronic disorders such as back pain, chronic heart fail- threshold of 50,000/QALY, although it may be cost-effective
ure, angina pectoris, and chronic obstructive pulmonary dis- at a higher threshold of $100,000/QALY [79].
ease [63, 64]. Moreover, the consequences on the working The median cost for full endoscopic sinus surgery (ESS)
population result in loss of productivity [39, 65]. This impair- which includes the frontal sinuses was $4281 as compared to
ment can be attributed to the detrimental health effects of intermediate ESS (total ethmoid, maxillary) $3716 and ante-
CRS, which include chronic pain [66], headache [67], nasal rior ESS (anterior ethmoid, maxillary) $2549. Full ESS with
dysfunctions [68], loss of sleep [69, 70], fatigue [70], depres- frontal sinus surgery had operative duration, total cost, and
sion, cognitive impairment, and acute infections [71]. supply costs that were 1.37, 1.52, and 2.40 times greater than
Common chronic conditions such as asthma, migraine, anterior ESS [80].
and diabetes have defined their burden of disease on society However, findings from these studies may not be general-
and economic evaluations of these chronic medical condi- izable to other patient populations and healthcare systems.
tions have helped healthcare providers better estimate the
associated social costs and cost-effectivity of treatments.
Contrary to this, there is not much data available to deter- 1.5.3 Medico-Legal Economic Burden
mine the cost-effectivity of treatment for CRS, though there
is increased understanding in its diagnosis, pathophysiology, Functional endoscopic sinus surgery (FEES) is one of the
and management options [39]. most litigated surgeries in otolaryngology. The location of
In 2007, a study conducted by Bhattacharayya et al. used the frontal sinus adjacent to the orbit and beneath the skull
the Medical Expenditure Panel Survey (MEPS) and a cost base presents the risk of potentially catastrophic complica-
estimation model (regression model) to estimate a cost of $ tions and unsatisfactory results.
8.6 billion per year, which would represent the approximate The most common complications listed in FESS lawsuits
national healthcare expenditure of CRS in the USA [72–74]. are intracranial complications (including cerebrospinal fluid
The survey results showed that the direct cost was primarily [CSF] leak), orbital injuries (including blindness), and anos-
attributed to medication use, physician’s office consulta- mia. The highest awards were in cases of CSF leak, anosmia,
tions, and emergency department visits. An additional study blindness, wrongful death, and intractable pain.
used a similar methodology with MEPS and four established Lynn-Macrae and colleagues performed the first study
cost estimation protocols and found that the estimated cost of reviewing malpractice litigation resulting from injuries sus-
CRS-associated disease in 2011 was $ 60.2 to $ 64.5 billion tained during ESS. They found 41 cases that were decided or
in the USA [75]. Costs of illness arise primarily from ambu- settled between 1990 and 2003. Negligent technique in 31
latory, followed by in-hospital, outpatient, prescription drug, (76%) was the most frequent cause reported, followed by
and emergency room (ER) visit costs [76]. lack of informed consent in 15 (37%) and wrongful death in
It has been estimated that in the USA, productivity costs 2 cases (5%). The average award was $751,275, with a
represent a significant economic loss to society and about $ median of $410,239 and a range of $61,000 to $2,870,000
260 billion is lost every year [77]. [81, 82].
A more recent study by Winford et al. obtained similar
results. The most common alleged injuries included CSF
1.5.2 Costs of Surgical Intervention leak, meningitis, orbital trauma, and nasal obstruction.
The cases won by plaintiffs (70% of cases in which out-
The reported costs of ESS range from approximately $3600, comes were known) were all in a private practice setting,
to over $10,500 USD [14]. In a study conducted by Gliklich with mean award of $225,000 and mean settlement of
and Metson, the costs of surgery were defined as the total of $212,500 [83].
10 C. Rawal and P. Corriols

Surgeons should also be cautious when operating on 1.6.1 Skill-Oriented Risks

patients for facial pain because either migraine, allergy, or
atypical facial pain may mimic sinusitis, and surgery is not Frontal sinus endoscopic surgery requires a detailed under-
likely to improve pain over the long term in this patient standing of frontal sinus anatomy and anatomic variants that
population. lead to obstruction of the nasofrontal outflow tract [87].
Radiological understanding of frontal sinus is of paramount
importance for surgical perspective, which is discussed in
1.6 Safety Concerns another chapter. The surgeon should know the anatomical
location and landmarks during surgery, without solely rely-
Frontal sinus diseases are potentially devastating because of ing on image guidance or surgical navigation technology.
their risk of causing an intracranial complication. The typical margin of error of navigation systems is 1–2 mm,
The primary goal of endoscopic frontal sinus surgery for the skull base and lamina papyracea are only 0.1 mm thick.
CRS is to provide improvement in the quality of life (QOL) Overreliance on surgical navigation can result in signifi-
of patients who have failed with medical therapy [12, 15] but cant complications.
endoscopic frontal sinus surgery has been considered diffi- If the surgical field is obscured by blood, topical vaso-
cult, hazardous, and likely to result in a high failure rate [16]. constrictor agents or warm saline irrigations should be used
This high failure rate is attributed partly to the varying fron- to decrease bleeding and improve visualization (see Chap.
tal sinus anatomy that offers great challenges to the surgical 5). If hemostasis and appropriate visualization cannot be
interventions of the frontal sinus. The frontal sinuses rest obtained, the surgeon should stop and consider a staged
above the frontal beak in the frontal bone with an outflow procedure. The surgeon’s own experience and knowledge
tract nestled between the orbits laterally and skull base medi- of his or her own limitations should be kept in mind for
ally. These fundamental limits of dissection provide what is performing a safe surgery [88]. If the situation requires, the
frequently the narrowest sinusotomy, as well as the highest surgeon should not hesitate to refer the patient to a more
risk for major complications and stenosis. Extensive research experienced surgeon.
is essential for developing an evidence-based approach to Frontal sinus surgery units should offer excellent patient
frontal sinus surgery. care. They must be staffed by rhinologists with training in
Frontal sinuses are located superior to the eyes within the advanced endoscopic sinus surgery, and the operating theatre
frontal bone, they are absent at birth though development configuration should be equipped with specific instrumentation
starts in fourth gestational month. They have a different rela- for the frontal sinus approach and, if possible, a neuronaviga-
tion to the lateral wall of the nose depending upon their ori- tion assistance system for ESS. The burden of direct and indi-
gin; they become well developed by age 6 and reach their full rect cost of the disease, treatments, substantial cost to society,
size around age 12–16. They develop as the superior exten- complications and litigations, the cost of advanced technology
sion of the anterior ethmoidal sinus and complete their and equipment demand high specialized and dedicated teams
growth by the age of 20. The typical volume of the frontal and provides a strong incentive to optimize current treatment
sinus at the adult stage is 4–7 ml. protocols and emphasizes the need to continue evaluating novel
Various anatomic studies have revealed variations that are clinical interventions to improve outcomes and to reduce costs.
associated with disease and pose challenges for surgery. The
surgeon should have wide knowledge regarding these anom-
alies and anatomical variations preoperatively so he can 1.6.2 Informed Consent
avoid the risk of intraoperative complications such as intra-
cranial penetration. Frontal sinus aplasia is one such anom- An informed consent, which is a medico-legal document
aly that is defined as the absence of frontal bone with detailed discussion about potential complications and
pneumatization. Therefore, looking for an absent frontal alternative treatments, must be obtained from the patient.
sinus may result in catastrophic complications during endo- Physicians must describe the recommended treatment or
scopic sinus surgery. Computed tomography involving mul- procedure to the patient and disclose the benefits, risks,
tiplanar reconstruction is essential to confirm the existence potential complications, and alternatives to the proposed
of frontal sinus. The prevalence of bilateral frontal sinus treatment or procedure (including no treatment). The poten-
aplasia varies between different populations and it ranges tial need for an open approach (trephination, osteoplasty)
between 3% up to 10% [84]. In Alaskan Eskimos and should be discussed with the patient. An often-quoted figure
Canadian Eskimos, it reaches 25% and 43%, respectively is that the risk of serious complications of sinus surgery is
[85, 86]. approximately half of 1% [89].
1  An Overview of Frontal Sinus Surgery. Past, Present and Future 11

Lynn-Macrae and colleagues reported in their study major alter facial growth. Other concerns are the proximity of vital
and catastrophic injuries caused by sinus surgery, including structures, bone fragility, and smaller anatomy, which makes
CSF leak (24%), diplopia (17%), brain damage (15%), and avoiding stenosis of the nasofrontal duct more difficult.
death (5%) [81]. Appropriate preoperative counseling is not Endoscopic approaches to the frontal sinus are preferred.
only important to discuss risks, alternatives, and benefits, but
it also increases patient understanding and comfort with sur-
gical intervention and facilitates postoperative adherence 1.8 Conclusion
necessary for a successful outcome [90].
Revision surgery is considered to carry an increased risk Frontal sinus surgery is the most challenging paranasal sinus
of complications due to altered anatomy and scarring. surgery. Endoscopic approaches have revolutionized the
However, a recent study did not observe a significant differ- field of frontal sinus surgery and have become the standard
ence in the rate of major complications in primary FESS approach in treating frontal sinus diseases. There have been
(0.36%) versus revision cases (0.46%). This study identified great advances in ESS in recent years, particularly prominent
a lower incidence of complications than in previous studies. in frontal sinus surgery. New anatomo-surgical, radiological
However, frontal sinus surgery was associated with a higher classifications and descriptions of the complexity of the sur-
risk for major complications, along with age, insurance sta- gery, also aided by advances in imaging processing tech-
tus, and image guiding employed during surgery [91, 92]. niques, surgical instruments, navigation systems, pre-surgical
checklists, pre-, intra-, and postoperative management have
greatly improved the safety and results of this complex sur-
1.7 Complications of Frontal Sinus gery which has a potential risk of major complications. More
Surgery research is needed to explore the cost-effectiveness and vari-
ability of the various surgical approaches.
Because of the anatomical location and venous drainage pat-
tern of the frontal sinus, complications commonly involve
intracranial structures. Sometimes orbit, bone and soft tissue References
structures can also get involved and injured. Complications
of frontal sinus surgery can be classified depending on the 1. Runge: Cited by Stevenson RS, Guthrie D. A history of otolaryn-
gology. Baltimore: Williams and Wilkins; 1954.
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3. Luc H. Lecons sur le suppurations de l’oreille Moyenne et des cavi-
• Endoscopic approach: ties accesoires des fosses nasales et leurs complications endocrani-
–– Major complications include meningitis, brain abscess, ennes. Paris: Baillere; 1900.
4. Ramadan HH. History of frontal sinus surgery. Arch Otolaryngol
CSF leaks, intraorbital hemorrhage, diplopia, blind- Head Neck Surg. 2000;126:98–9.
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 Training in Frontal Sinus Surgery
2
Gaurav Medikeri

2.1 Introduction acute ethmofrontal angle would be the easiest configuration

for beginners. The international classification of complexity
Frontal sinus is one of the most challenging sinuses to tackle, of frontal sinus surgery explains the grades of complexity of
more so for beginners [1]. Some of the most important fac- the frontal sinus cellular arrangement, which a trainee can
tors in completing successful frontal sinus surgery include, adopt to begin training in frontal sinus surgery [5] (see Chap.
understanding the anatomy of the frontal sinus outflow tract, 6). Cells above the frontal ostium with a narrow anteroposte-
adequate planning, proper instrumentation, and good rior diameter of the sinus have a higher complexity rating as
follow-up. The use of angled endoscopes requires a paradigm compared to cells below the ostium with a wider anteropos-
shift in the maneuvering of instruments and hand–eye terior diameter. The trainee must begin with the latter
coordination. This period of adjustment to acquire these new arrangement during their training course.
set of skills is labeled as “the learning curve.” Cadaver
courses studying the completeness of dissection found that
experienced surgeons had more complete frontal recess 2.2 Cadaver Dissections, 3D Models,
dissections, indicating that they had crossed this learning and Virtual Reality
curve and become more confident in managing complex
pathologies [2]. Once the trainee has completely understood the anatomy and
Frontal sinus surgery training must begin in a gradual and the various cells that could make up the frontal recess, the
incremental manner to obtain the best results during surgery. next stage would be to undertake cadaver dissections or 3D
Sticking to such a training module would reduce the risk of constructed model based dissection. Cadaver-based simula-
complications and would increase the confidence level of the tion exercises have been shown to improve resident operative
trainee [3]. The use of a medical imaging software prior to autonomy by exposing them to operative maneuvers much
surgery has been shown to be a useful way to understand the earlier in their training [5]. Cadaver dissections would obvi-
frontal sinus drainage pathway [4]. The trainee must begin ously be the gold standard in surgical training, but due to the
with a simple setting of the anatomy of the frontal recess lack of a steady flow of cadavers through donations, limited
cells. Cells below the frontal ostium such as the agger nasi, number of skills and training labs, the lack of reusability of
supra agger cell, or the supra bullar cell would be an easy cadavers, and the high cost of such courses, makes it difficult
architecture to start with. Other parameters, which determine to train through this route on a regular basis (Fig. 2.1).
the ease of opening the frontonasal drainage pathway, include With the advent of 3D printing, it is now easy to create
the anteroposterior diameter of the frontal sinus and the these models, which serve as high fidelity low cost tools to
ethmofrontal angle. A wide anteroposterior diameter with an train students in endoscopic sinus surgery [6]. Patient scans
can be used to recreate 3D models of patient’s specific anat-
G. Medikeri (*) omy using 3D visualization software. This could help in
Endoscopic Sinus and Skull Base Surgery, Liverpool, UK understanding the cells arrangement and technical difficulty
Endoscopic Sinus and Skull Base Surgery, Vancouver, BC, Canada in terms of space constraints in the frontal recess, the logis-
tics necessary to maneuver instruments in the recess, use of
Rhinoplasty and Facial Cosmetic Surgery, Seoul, South Korea
angled endoscopes and instruments [7–10]. The advantage
Medikeri’s Superspeciality ENT Center,
of 3D reconstructed models is that varying range of com-
Bangalore, Karnataka, India
plexities can be created depending on the experience of the
Skull Base Unit, Health Care Global Hospitals,
trainee and difficulty levels can be built up from there [11,
Bangalore, Karnataka, India

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 15

D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_2
16 G. Medikeri

Fig. 2.1  Cadaver dissection at the Endoscopic Sinus Surgery Course, Hospital Virtual Valdecilla, Santander, Spain, 2021. Courtesy of Dr Lobo

12]. At some centers, artifacts are added to the 3D model to before the trainee can then perform the procedure themselves
simulate pathology- like orange flesh for polyps, sticky paper under guidance. In order to correctly “direct” the surgeon, the
mache glue for mucin, etc. Use of such cadaveric or simula- trainee will need to have a sound understanding of the ana-
tion models has shown a significant drop in the reaction time tomical architecture of the frontal recess. For this, the trainee
and complication rates and such objective improvements in must regularly study CT scans and observe the surgeon while
performance have shown to improve patient outcomes [13]. they are operating so as to understand the maneuverability of
Virtual reality (VR) is now being used across many plat- different instruments when angled scopes are being used. It is
forms—from laptops to smartphones and across many sce- recommended that the trainee logs these details in their log-
narios—from gaming to surgical training [14]. The cost of book as to how well they have guided the surgeon to the fron-
implementing VR into surgical training has been greatly tal sinus and in the cases they got wrong, it is imperative that
reduced, making it easier to use on a regular basis. Although they go back and study the anatomy again carefully, so that
it is a more controlled manner of training, it does not provide the same mistake is not repeated consistently. This would
real life tissue feel and feedback that a fresh cadaver or a live help ameliorate the negative effects of the learning curve
patient would provide. Haptic feedback is vital to safely involved in frontal sinus surgical training.
maneuver endoscopic instruments in patients, especially Once the surgeon is confident that the trainee is consis-
near vital structures [15]. Despite the advances in 3D tently getting the frontal pathway correct, then under the
technology and VR simulation, we are still a long way from guidance of an experienced surgeon, the trainee is allowed to
giving trainees a realistic experience for advanced sinus open the frontal recess. On the day of surgery, the trainee
surgery training. The trainee would definitely have a better must explain the 3D anatomy of the frontal recess in the case
overall experience from a fresh cadaver in terms of haptic to be operated and describe in writing with the help of dia-
feedback, tissue feel, mucosal trauma, identification of grams—the steps he/she will follow and what they will
olfactory area, etc. [16] encounter after each cell is opened. It is prudent that the
After the trainee has completed a good number of certified surgeon initially gives them cases that are relatively easy to
hands-on courses, the next step would be assisting surgery perform. This would mean an anatomical architecture, with
with a trained surgeon. At our center, it is a routine for the cells below the frontonasal beak. At any point in surgery, if
trainee to “direct” the surgeon verbally towards the frontal the consultant feels that the trainee is not sticking to the plan
sinus correctly and consistently in at least 50 cases (arbitrary) or is on the verge of complicating the surgery, then it is
2  Training in Frontal Sinus Surgery 17

imperative that they take over and complete the surgery Figure 2.2 shows the workflow for residents when they
while correcting the trainee as to why and where they went start training in frontal sinus surgery.
wrong. The trainee must go back to the CT scan, correlate
their steps of surgery with the scan, and understand where
they went wrong—planning, or execution. This data must be 2.3 Factors Leading to Successful Training
clocked in the logbook and the whole surgery must be
recorded by the trainee. This would help the trainee to revisit With hospitals being overcrowded and operating lists piling
the surgery in case there was a complication and to correct up, consultants are also under pressure to complete the
their steps during subsequent surgeries [17]. stipulated surgeries for the day and may not be in a position
After being consistent and confident in identifying the to allow plenty of time for the trainee to take their time to
frontal sinus outflow tract, maneuverability of instruments, perform the procedure. It is therefore advisable that the
360 degree mucosal preservation around the frontal sinus training be carried out in small steps. The surgeon must
outflow tract without the surgeon having to step in and take supervise the trainee in performing the initial steps and once
over the case in at least 25 to 30 Level 1 to 2 cases, the he/she is able to perform the step completely independently
trainee must now proceed to a more complex anatomical and consistently, only then they must be allowed to progress
organization with cells above the frontonasal beak. This to the next step. For example, the trainee must begin with
would require the trainee to be able to use longer instru- decongestion of the frontal recess without mucosal injury or
ments and work through the hourglass narrowing at the damaging the cellular architecture. Until the trainee can
level of the frontal beak. There is a very high chance that achieve this feat independently, he/she must not proceed to
mucosa might be disrupted and the trainee must be given open the frontal recess cells. The next step after decongestion
sufficient time to open the cells without disrupting the would be to identify the frontal drainage pathway and open
mucosa. The above said methodology would help in gradu- the cells below the frontal beak without damaging mucosa
ally transitioning the resident from direct supervision to a and using the right instruments for the situation. Progressing
state of resident operative autonomy with indirect operative step-wise would gradually build the confidence level of the
supervision [18]. trainee and thus allow learning in small packets rather than

Fig. 2.2  Flow chart to

explain the training process Anatomical study & study of CT scans to assess different types of cellular arrangement.
for residents

3D model dissections, cadaver dissections & Virtual reality for better anatomical clarity & hand eye
coordination.

Studying pre-operative scans and “Guiding” the surgeon to the frontal sinus consistently and correctly
during surgery.

Opening the frontal sinus with simpler anatomical architecture (cells below the frontal beak) under the
supervision of an experienced surgeon & getting it consistently correct.

Being consistent with opening the frontal recess with complex cellular architecture (Cells above the
frontal beak) under the supervision of an experienced surgeon without any mucosal trauma in the
recess. At this point, the resident can open simple anatomical configurations independently.

Independently opening the frontal recess with complex cellular architecture.

Frontal sinus drill out procedures.

18 G. Medikeri

trying to do everything incompletely and not reaching Table 2.1  Requisites and responsibilities of trainees and trainers
anywhere. Being perfect in small steps would also boost the Trainee Surgeon
morale of the trainee and help increase the trust of the trainer Willingness to dedicate time to Should suggest reading
in the trainee. reading and understanding the materials and videos to help
complex anatomy of the frontal the trainee better understand
There are three main factors, which can determine suc- recess the anatomy and physiology of
cessful outcomes in training: the sinuses
Willingness to approach the Must have sound knowledge
1. Faculty supervision. surgeon for any difficulties faced and adequate experience of
in understanding the subject complex cases. Must be an
2. Appropriate resident autonomy.
authoritative figure with
3. Patient safety in the operating room. leadership qualities, yet
approachable
The balance between these three factors is what will Should be able to participate in Must be able to attract
ensure that proper training can be carried out without com- hands-on courses sufficient cases into his/her
practice of varying complexity
promising patient safety. The ability of a faculty to trust a
Observe and log their cases Must have the eagerness and
trainee and the ability of the trainee to win the trust of the regularly—must mention what patience to train the trainee by
faculty are both crucial for the trainee to progress the ladder they learnt from that particular being in the operating room.
of entrustability and operative autonomy in the operating case that they observed, assisted, Need to verify logbooks to
or performed (under supervision ensure that the entries are valid
room. Most faculty in medical practice are good surgeons
as well as independently)
but the same cannot be said about being good teachers, as Should not be overly enthusiastic Should not hesitate to correct
they have not received any formal training in running a and must know their limitations the trainee or take over if he/
teaching program. There has to be a paradigm shift, so that during surgery. Must not hesitate she feels that the trainee is
the faculty can facilitate gradual autonomy and must merely to seek help/guidance if unsure going off course or is not
within the safe limits of
be present in the operating room rather than drive the proce- surgery
dure themselves, but keeping patient safety at the forefront. Must follow up cases operated or Must have enough experience
Developing such strategies will eventually improve the con- assisted by them to understand and should be confident
fidence and surgical skills of the trainees, who will eventu- how intraoperative maneuvering enough to handle any
ally take care of the patients in the future [19]. There is of instruments influences complications that may arise
outcomes after surgery out of the surgery done by the
evidence to suggest that residents who are familiar with the trainee
faculty have higher chances of developing operative auton- Must be diligent in reporting Must be patient enough and
omy earlier on in their training period [20]. complications and learning from should be able to guide the
Currently, there are no validated training methods or them trainee through the whole
procedure rather than having a
courses to assess the success of a trainer. However, a recent “I’d rather do it myself”
meta-analysis of 14 articles has divided the attributes of a attitude
successful trainer into four categories [21]: Must be able to obtain patient Must not put undue pressure
consent and must be aware of the onto the trainee to finish the
1. Character complications that can arise with surgery or lose patience when
the procedure trainee is taking time within
(a) Approachability reasonable limits
(b) Patience Should also have a sense of Should be willing to take
(c) Enthusiasm responsibility towards the patient responsibility for any
(d) Encouraging/supportiveness operated by them and must follow complications that may arise
up with the patient and inform the during training and would be
2. Operative surgeon about the well-being or responsible for the patient at
(a) Willingness to let trainee operate worsening of the patient’s the hospital morbidity or
(b) Balance between supervision and independence condition in case of a mortality meetings
3. Teaching and communication complication
(a) Sets educational aims and objectives
(b) Ability to use appropriate feedback Thus, it can be said that training requires an effort from
(c) Communication skills both ends—a good trainee will show the requisite enthusi-
(d) Time availability to train asm and willingness to have an open mind to learn, whereas
4. Clinical a good trainer would acknowledge the effort and work
(a) Capable towards honing the skills of the trainee. Table 2.1 enlists the
(b) Good relationships with patients and the health care qualities that a good trainee and a trainer must possess in
team order to smoothen the process of frontal sinus surgical train-
2  Training in Frontal Sinus Surgery 19

ing. Although this list is arbitrary and there might be many References
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pushing their limits by taking on more complex and compli- org/10.1016/j.jsurg.2016.06.014.
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els or the outcomes of surgery. Thus, it is advisable that tion in investigating the frontal sinus drainage pathway based on
computer tomography data. Lin Chung Er Bi Yan Hou Tou Jing
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duration exposure to high volume rhinology centers every issn.1001-­1781.2018.03.003.
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tal sinus anatomy classification anatomic models for resident edu-
remain confident of the anatomy, technical challenges, and cation. Otolaryngol Head Neck Surg. 2019;161(4):705–13. https://
instrumentation needed to conduct safe and effective frontal doi.org/10.1177/0194599819860832.
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such a facility available to general otolaryngologists where MA.  Development and validation of a 3D-printed model of the
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Hsieh TY, Cervenka B, Dedhia R, Strong EB, Steele
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ing time, and complication rates. Operating with the help of Laryngoscope. 2014;124(3):596–601. https://doi.org/10.1002/
simulation with pre-loaded scans of the patients is one way lary.24316.
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pre-operative scans correlates quite well with post-operative G. Objective validation of perfusion-based human cadaveric sim-
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14. Fried MP, Sadoughi B, Gibber MJ, Jacobs JB, Lebowitz RA, Ross ment with resident autonomy in the operating room. JAMA Surg.
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reality to the operating room: the endoscopic sinus surgery simula- 20. Sandhu G, Thompson J, Matusko N, Sutzko DC, Nikolian VC,
tor experiment. Otolaryngol Head Neck Surg. 2010;142(2):202–7. Boniakowski AE, Georgoff PE, Prabhu KA, Minter RM.  Greater
https://doi.org/10.1016/j.otohns.2009.11.023. faculty familiarity with residents improves intraoperative entrust-
15. Favier V, Najaf Y, Captier G.  Validation of haptic properties of ment. Am J Surg. 2020;219(4):608–12. https://doi.org/10.1016/j.
materials for endoscopic sinus and skull base surgery simula- amjsurg.2019.06.006.
tion. JAMA Otolaryngol Head Neck Surg. 2018;144(12):1184–5. 21. Dean B, Jones L, Garfjeld Roberts P, Rees J.  What is known
https://doi.org/10.1001/jamaoto.2018.1810. about the attributes of a successful surgical trainer? A systematic
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tors in otolaryngology. Otolaryngol Clin N Am. 2017;50:875–91. jsurg.2017.01.010.
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cation an effective method in surgical education? A systematic B.  Training, practice, and referral patterns in rhinologic surgery:
review. J Surg Educ. 2018;75(5):1150–8. https://doi.org/10.1016/j. survey of otolaryngologists. J Otolaryngol Head Neck Surg.
jsurg.2018.01.014. 2010;39(3):297–303.
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23. Won TB, Cho SW, Sung MW, Paek SH, Chan S, Salisbury K,
RM. Progressive entrustment to achieve resident autonomy in the Blevins NH, Vaisbuch Y, Hwang P. Validation of a rhinologic vir-
operating room: a national qualitative study with general surgery tual surgical simulator for performing a Draf 3 endoscopic frontal
faculty and residents. Ann Surg. 2017;265(6):1134–40. https://doi. sinusotomy. Int Forum Allergy Rhinol. 2019;9(8):910–7. https://
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KA, Matusko N, Minter RM.  Association of faculty entrust-
 Frontal Sinus Classical and Endoscopic
Anatomy 3
Irene Monjas Cánovas and Elena García Garrigós

3.1 Introduction 3.2 Frontal Bone

Surgical management of the FS is considered one of the most The frontal bone is located at the most anterior part of the
difficult and challenging procedures of endoscopic sinus sur- cranium. It is made up of two main parts: a horizontal and a
gery. Operating endoscopically in the FS is challenging not vertical portion (Fig. 3.1). The horizontal or orbital portion
only because of the complex anatomy and its anatomical forms part of the roof of the orbital and nasal cavities and
relationships (anterior skull base, anterior ethmoidal artery, acts to floor the frontal lobes of the brain. The vertical or
orbit) but also because of ergonomic factors that lead the sur- squamous portion is flat and marks the main region of the
geon to perform the surgery in an oblique plane in a narrow forehead (Fig. 3.2.). It contains the FS which is surrounded
space with a hard visualization and instrumentation. Finally, by two walls of cortical bone. The posterior wall of the FS,
due to the great individual variability in this region, anatomy which separates the sinus from the anterior cranial fossa, is
may vary among individuals. Thus, specific radiologic stud- much thinner (less than a millimeter in some areas) than its
ies are mandatory for surgical planning. anterior wall [1] (Fig. 3.3).
Imaging techniques, especially computed tomography The FS is not present in the newborn but makes its appear-
(CT) images, provide the surgeon with information about ance in the orbital plate between the end of the first year and
anatomical structures and variants for planning the surgery the beginning of the third year. They are generally well
to avoid complications or failure. Similarly, as with any sur- developed and functional between the sixth and the eighth
gery, thorough anatomical knowledge is part of a successful years, although they continue to grow slowly until reaching
surgical procedure. In this chapter, we will go through the their maximum size after puberty [2]. Frontal sinuses are
main anatomical references to perform a safe endoscopic rarely symmetrical as they develop independently. They
approach to the FS. We will review the FR anatomical limits assume the shape of a pyramid and their average measure-
and we will discuss how to manage the different anatomical ments are as follows: height 28 mm, breadth 24 mm, depth
variants in this region. We will correlate the FS and FR clas- 20 mm, creating a space of 6–7 ml [3].
sical anatomy to the endoscopic and radiological anatomy. A triangular-shaped intersinus septum separates the fron-
The key point to perform a safe and successful frontal sur- tal sinuses into separately draining sinus cavities. It is the
gery is to unify the three concepts and to be able to create and continuation, anteriorly, of the ossified embryologic sagittal
reconstruct mentally a 3D configuration with the important suture line. Although the intersinus septum may vary in
landmarks and risky regions before coming to the operating direction and thickness as it proceeds superiorly, the base of
room. the intersinus septum will almost always be close to the mid-
line at the level of the infundibulum. At this level, the intersi-
nus septum is continuous with the crista galli posteriorly, the
perpendicular plate of the ethmoid inferiorly, and the nasal
spine of the frontal bone anteriorly. The falx cerebri inserts
I. M. Cánovas (*) into the posterior table of the frontal sinus, at a point corre-
ENT—Department, Hospital General Universitario de Alicante sponding to the posterior edge of the intersinus septum [1].
(Alicante), Alicante, Spain
There are wide variations in the pneumatization of the
E. G. Garrigós FS: the frequency of bilateral absence of the FS has been
Radiology—Department, Hospital General Universitario de
reported in 3–4% to 10% of several populations [4]. Superior
Alicante (Alicante), Alicante, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 21

D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_3
22 I. M. Cánovas and E. G. Garrigós

a b d

Ethmoidal notch
Fovea ethmoidalis

c e

Supraorbital Supraorbital
foramen Notch

Fig. 3.1  Frontal bone I. (a) The frontal bone is located at the most Laterally it makes up a great part of the roof of the orbits. Medially, it
anterior part of the cranium. The external portion consists of two parts. contributes to the roof of the nasal cavity. (e) Both portions are divided
(b) Vertical or squamous portion. It builds up the main region of the by the nasorbital crest (dotted line). At around 3 cm from the midline,
forehead. (c) Horizontal or orbital portion. It projects posteriorly at the supraorbital foramen (right) and notch (left) can be identified (blue
almost a 90° angle from the vertical portion. (d) Horizontal portion. circle)

a b

Fig. 3.2  Frontal bone II. (a) Horizontal portion: Laterally it makes up a great part of the roof of the orbits. (b) Horizontal portion: Medially, it
contributes to the roof of the ethmoid
3  Frontal Sinus Classical and Endoscopic Anatomy 23

a b

Fig. 3.3  Frontal bone III. (a) Horizontal portion acts as the floor of the anterior cranial fossa. (b) Endocranial view of the frontal bone. (c) The
horizontal portion roofs the orbits laterally and the ethmoid medially

pneumatization can extent variably, and it reaches the nasal responds to the FR.  This morphology is more evident on
bones inferiorly. The main issue for endoscopic approaches the sagittal plane in CT images.
is to check out the lateral pneumatization: when extending The FR is a three-dimensional space occupied by several
far lateral in the coronal plane, the endoscopic approach can anterior ethmoidal cells that surround and address the direc-
be limited or even discarded. tion of the drainage [5]. Its configuration has a great variabil-
ity among individuals and depends mostly on the degree of
pneumatization of the different ethmoidal cells.
3.3 Frontal Recess Its posterior wall consists of the anterior wall of the bulla
ethmoidalis. If this lamella does not reach the skull base, the
The frontal sinus drainage pathway is highly variable and it frontal recess may open into the suprabullar recess.
has been classically compared to an hourglass shape. The Anteriorly, the recess is limited by the superior part of the
FS narrows down inferiorly and medially into a funnel agger nasi cell (ANC) (Fig. 3.6.). Its medial limit is repre-
shape point, which is the frontal infundibulum. It ends in sented by the vertical lamella of the middle turbinate and the
almost a circular area: the FS ostium which lies in an lateral lamella of the cribriform plate [6]. The FS drainage is
oblique plane between the skull base and the frontal beak. located in the center of the recess in 53% of cases, lateral in
The ostium is the area of transition from the FS to the FR 29%, and anterior in 11%. Asymmetry between both sides is
(Figs. 3.4 and 3.5). The inferior portion of the drainage cor- present in 46% of cases [7] (Fig. 3.7).
24 I. M. Cánovas and E. G. Garrigós

a b

FS
FS

Frontal Frontal
Reccess Reccess

Fig. 3.4  Frontal recess I. (a) The superior compartment corresponds to horizontal at the junction with the fovea ethmoidalis. Frontal Sinus: FS;
the frontal sinus, the inferior portion corresponds to the frontal recess, Dotted yellow Line: frontal sinus drainage pathway. Red asterisk: fron-
and the narrowest part is the frontal ostium. (b) The superior boundary tal ostium
of the FR slopes down posteriorly at a 15° angle and becomes more

Frontal bone tal beak, and shape of the skull base. These anatomical fac-
tors vary among individuals and races [8, 9].

Superior
portion FR 3.4.1 Agger Nasi Cell
Lamina
papyracea The ANC is currently considered the key to accessing the
Orbital process
maxillary bone

Unguis
frontal pathway drainage. It is the most anteriorly placed fron-
Nasal toethmoid cell and it is present in 98.5% of patients [10]. On
bone endoscopic examination, this cell appears as a prominence on
the lateral nasal wall just anterior to the attachment of the mid-
dle turbinate (Fig. 3.8). It is thought to be the most superior
remnant of the first ethmoturbinal (nasoturbinal) [11].
The ANC pneumatizes into the frontal process of the
maxilla and lacrimal bone area and it can be easily identi-
fied on the coronal CT scan as the first ethmoidal cell after
the lacrimal duct and anterior to the middle turbinate.
Fig. 3.5  Frontal recess II. The frontal recess is limited laterally by the However, sagittal reconstructions allow for a better analy-
orbital part of the frontal bone, the lacrimal bone, and a small part of the sis, visualization, and understanding of its variants. When
lamina papyracea
present, it appears as part of the anterior ethmoidal cells
building up the anterior and inferior limit of the frontal
recess. Due to its localization, a large ANC may push the
3.4 Anatomical Structures frontal recess posteriorly and/or medially but it is also often
associated with a larger anteroposterior surgical frontal
Despite all the “fixed” limits, the anatomy of the FR is highly opening [12, 13].
variable and the FS outflow tract is determined in general The posterior and superior portion of the UP together
terms by the pneumatization pattern of the FR cells, the with the medial wall of the ANC is the key that unlocks the
attachment of the uncinate process (UP), the size of the fron- frontal recess. Most of the ANC is anterior to the uncinate,
3  Frontal Sinus Classical and Endoscopic Anatomy 25

a b c

d e f

b
a b

Fig. 3.6  Frontal recess limits. Complex and varied anatomy, whose nate and the vertical lamella of the cribriform plate (green line). Yellow
direction, size, bending, and relationship with the ethmoid infundibu- dotted line: frontal sinus drainage pathway. (a) Schematic sagittal draw-
lum are altered by the configuration of air cells within it and the differ- ing of the frontal recess. (b) Sagittal CT view of the frontal recess. Note
ent attachments of the UP (u). Located posterior to the frontal beak (red the structures that build up the anterior and posterior limits of the fron-
asterisk) and agger nasi cell (ANC), anterior to the bulla ethmoidalis tal sinus drainage pathway. (c) Coronal CT view. Note the lateral and
(BE), and the anterior ethmoidal artery (AEA) in between the lamina medial limits of the frontal recess. (d–f) Sagittal CT view of the frontal
papyracea (dotted red line) and the vertical lamella of the middle turbi- recess

but the posterior half of the ANC has an intimate relationship 3.4.2 Uncinate Process
with the upward extension of the UP [14]. Stamm [15] calls
this relationship “vertical bar” and supports that usually the The UP is the most anterior bony lamella, of the four lamel-
frontal recess drains medial or posterior to this structure. lae that traverse the entire ethmoid (UP, bulla lamella, basal
In fact, to perform a type I Draf frontal sinusotomy, lamella of the middle turbinate, and basal lamella of the
which is really part of the anterior ethmoidectomy [16], the superior turbinate). There is a fifth lamella that corresponds
ANC has to be removed. For that purpose, a Kerrison for- to the supreme turbinate. It has a prevalence of 60% and may
ceps can be used to eliminate its anterior wall. Once it is present unilaterally or bilaterally [21].
open, the posterior wall can be assessed and removed, enter- It is a thin sickle-shaped bony structure with an almost
ing directly into the frontal recess that can be permeable or sagittal orientation, running from anterosuperior to postero-
occupied by other FR cells. This has to be established as a inferior. Its free posterior margin runs parallel to the anterior
key landmark for the FR dissection in basic and advanced surface of the ethmoid bulla. The course of the free inferior
surgery [17]. edge of the UP usually attaches to the perpendicular process
Because surgeons lack confidence when exploring this of the palatine bone and the ethmoid process of the inferior
area, inadequate removal of cells and eventually disease turbinate (Fig.  3.9). For frontal endoscopic surgery, under-
often occurs. The strong correlation of ANC disease with FS standing the superior attachment is more useful.
disease assessed by sinus CT scans in patients undergoing Traditionally, the superior attachment of the UP has been con-
revision surgery has been described in the literature sidered as the key to treating the FR with its three types of inser-
[18–20]. tion: lamina papyracea, skull base, and middle turbinate [22].
26 I. M. Cánovas and E. G. Garrigós

a b
FS FS Nasal
spine

* * LP
AEA Roof orbit
AEA Roof orbit
EN
LP
FE
FE AEA
AEA

AEP
AEP

c d

Roof orbit Roof orbit Roof orbit Roof orbit

CP
FE FE

Fig. 3.7  Endoscopic limits of frontal bone. (a) Endoscopic view after by the cribriform plate (yellow area or CP). AEA: Anterior ethmoidal
Draf III procedure. (b) Inferior view of frontal bone. (c) Inferior view of artery; AEP: Posterior ethmoidal artery; LP: Lamina papyracea; FS:
the frontal bone showing the roof of the orbits laterally and the fovea Frontal sinus; Red asterisk: Vertical lamella, cribriform plate; EN:
ethmoidalis (blue area or FE). (d) Inferior view of frontal bone showing Ethmoidal notch; FE: Fovea ethmoidalis
the roof of the orbits laterally and the ethmoidal notch medially filled up

When the UP attaches to the lamina papyracea, which is However, Wormald showed that the location of the
the most common situation as it is seen in 60–88% of cases, superior insertion of the UP is often a secondary effect of
the ethmoid infundibulum ends up in a blind recess known as the degree of pneumatization and morphology of the
the recessus terminalis and the superior portion of the UP ANC [24].
makes up the posterior wall of the ANC. In such cases, the In addition, the UP, similar to other structures of the eth-
frontal drainage runs directly into the middle meatus medial moid, can present a great variability with multiple superior
to the UP (Fig. 3.10). attachments [25].
In cases where the UP attaches to the skull base or the For all these reasons the upper classification has to be
middle turbinate, the frontal drainage is directed into the eth- taken into account but it should be completed with a proper
moidal infundibulum, lateral to the UP which can be seen in interpretation of the CT scan. DICOM readers like Horos or
around 12–40% of cases [23]. Osirix can be a useful tool before surgery to draw a 3D con-
3  Frontal Sinus Classical and Endoscopic Anatomy 27

a b

c d

Fig. 3.8  Agger nasi cell. (a, b) Right nasal fossa. Endoscopic view showing the anterior wall of the agger nasi cell. (c, d) CT reconstruction in the
coronal and sagittal planes showing an agger nasi cell. Red asterisk: Agger nasi cell; Yellow dotted line: Frontal sinus drainage pathway

figuration of the frontal drainage and to be able to establish if These cells and the different anatomical variants have
the FS is draining in a medial or a lateral disposition. been well described by Bent and Kuhn [26, 27] and their
identification requires careful analysis of CT images in the 3
planes of space.
3.4.3 Frontal Cells They describe the frontal cells at the anterior portion of
the FR and propose four main cell types: type 1 is defined
The FR is the most inferior portion along the frontal drain- when there is only one cell above the ANC; type 2 occurs
age pathway and corresponds to the anterior ethmoid. It can when two or more cells pneumatize above the ANC; type 3
be very variable in shape and dimensions among individu- occurs when a large single cell pneumatizes above the ANC
als depending on the different ethmoidal cells that may nar- into the FS; and type 4 when there is an isolated cell within
row the airspace: in the sagittal plane they can be identified the FS.
in an anterior or posterior disposition in relation to the Recently, Wormald described an anatomical classification
pathway. based on three cell types: the anterior cells (ANC, supra-­
28 I. M. Cánovas and E. G. Garrigós

a b

* *
*

c d

*
*

Fig. 3.9  Uncinate process. (a) Endoscopic view of the left nasal fossa. (b) Axial CT view of the UP. (c) Sagittal view of the UP in cadaver bone.
(d) Sagittal CT view. Note the insertion of the UP in the agger nasi cell. Red asterisk: uncinate process; a: agger nasi cell; b: bulla ethmoidalis

agger cell, supra-agger frontal cell) that push the FS drainage mandatory for the understanding of the anatomy of the
pathway medial, posterior, or posteromedially; the posterior patient and individualized surgical planning.
cells (suprabulla cell, suprabulla frontal cell, supraorbital While the frontal cells are anatomic variants of anterior
ethmoid cell) that push the drainage pathway anteriorly; and ethmoid pneumatization located on the anterior margin of
medial cells (frontal septal cell) that push the drainage path- the FR that potentially extend within the airspace of the
way laterally [12]. frontal ostium above the ANC, at the posterior margin of
the FR, the bulla ethmoidalis forms the posterior boundary.
In some cases, the anterior bulla wall does not reach the
3.4.4 Frontobullar, Suprabullar skull base, creating a suprabullar recess. This space can be
and Supraorbital Cells filled up by one or more suprabullar cells. In addition, there
are other ethmoidal cells that may narrow the drainage of
The Draf I procedure consists of removing the ethmoidal the frontal sinus posteriorly: frontobullar or supraorbital
cells that surround the FR.  Thus, computed tomography is cells (Fig. 3.11).
3  Frontal Sinus Classical and Endoscopic Anatomy 29

a b c

Fig. 3.10  Superior attachment of the uncinate process. Schematic infundibulum. It forms a blind end to the ethmoidal infundibulum
coronal drawing and CT views of the most frequent variations of the superiorly called the terminal recess (recessus terminalis: rt). (b)
attachments of the vertical portion of the UP (red) and its relationship Attachment to the skull base. Frontal recess drains lateral to the UP and
with the frontal recess and frontal outflow tract (yellow) as proposed by joins to the ethmoidal infundibulum. (c) Attachment to the middle
Stammberger. (a) Attachment to the lamina papyracea (60–88%). turbinate. Frontal recess drains lateral to the UP and joins to the
Frontal recess drains medial to the UP, separated from the ethmoidal ethmoidal infundibulum

The frontobullar cells extend through the posterior aspect 3.5 Anatomical Landmarks
of the frontal ostium within the sinus. Supraorbital cells are
cells originating from the anterior ethmoid extending poste- 3.5.1 Lateral Lamella of the Cribriform Plate
riorly and superiorly over the orbit from the FR. They may
mimic septated frontal sinuses as their posterior wall is the The ethmoid labyrinth is covered by the fovea ethmoidalis of
skull base. These cells are present in 28–54% of subjects and the frontal bone. In the midline it attaches the lateral lamella
express the pneumatization of the orbital plate of the frontal of the cribriform plate, a very thin, sagittally oriented bone
bone posterior to the FR and the FS, as it can be seen in axial that defines the lateral wall of the olfactory fossa and entails
cuts. They appear in the sagittal reconstruction of the CT the posteromedial limit of the FR.
scan as triangular air cells with posterior vertex [28, 29]. The height of the lateral lamella defines the depth of the
When a supraorbital cell is present, the anterior ethmoidal olfactory fossa into the nasal cavity. Three classic heights
artery is usually seen freely running within the ethmoid air have been described by Keros [33]: type 1: has a depth of
cells and this increases the risk of intraoperative vascular 1–3  mm (26.3% of the population), type 2: has a depth of
injury (Fig.  3.12). The cell usually opens to the ethmoid 4–7 mm (73.3% of the population), and type 3: has a depth
anterior to the AEA [30]. They have also been significantly of 8–16 mm (0.5% of the population) (Fig. 3.13). Depending
associated with the presence of FS septations [31]. Finally, on the Keros type, the amount of lateral lamella exposed is
their presence has been associated with orbital proptosis in different. This means that Keros type 1 is the most favorable
patients with chronic rhinosinusitis [32]. situation as the lateral lamella exposure is just 1-3  mm,
30 I. M. Cánovas and E. G. Garrigós

Fig. 3.11  Suprabullar recess and supraorbital cells. Blue asterisk *: asterisk *: Supraorbital recess or cell: lateral extension of suprabullar
Suprabullar recess: air containing space bordered inferiorly by the roof recess or another aerated part of the ethmoidal roof extending over the
of the ethmoidal bulla (b), medially by the middle turbinate, laterally by orbit. B: bulla ethmoidalis
the lamina papyracea, and superiorly by the roof of the ethmoid. Green

whereas Keros type 3 is the most challenging scenario as ary of the FR slopes down posteriorly at a 15° angle and
more cribriform plate is exposed and can be potentially dam- becomes more horizontal at the junction with the fovea eth-
aged during manipulation, creating a cerebrospinal fluid moidalis. Just behind the junction, the AEA crosses the
(CSF) leak. medial orbital wall to the lateral lamella of the cribriform
plate [34].
The AEA usually runs along the skull base inside the
3.5.2 Anterior Ethmoidal Artery (AEA) anterior ethmoidal canal between the second and the third
lamella in around 100% of cases, in between the anterior and
The AEA is a key landmark for the fovea ethmoidalis, the the posterior walls of the bulla. With an angle of about 35°, it
anterior cranial base, and the FR. The FR lies just anterior to runs along the skull base in a very constant oblique direction
its course along the ethmoidal labyrinth. The superior bound- from posterolateral to anteromedial from the orbit to the
3  Frontal Sinus Classical and Endoscopic Anatomy 31

a b c

c d e

Fig. 3.12  Supraorbital cells. (a–c) CT reconstruction in the sagittal, runs far from the ethmoid roof surrounded by a mesentery, increasing
axial, and coronal planes showing a supraorbital cell. These cells appear the risk during surgery. (e) Endoscopic view after Draf III procedure
in the sagittal reconstruction as triangular air cells with posterior vertex and complete ethmoidectomy. Note the pneumatization over the orbit.
[28, 29]. (c, d) In these variants, the anterior ethmoidal artery (AEA) Red asterisk: AEA; Blue asterisk: supraorbital cell

olfactory groove. Finally, it reaches the olfactory groove in retinal artery. A medial injury where the artery enters the lat-
the vertical lamella of the cribriform plate, which is the eral lamella of the cribriform plate may result in a CSF leak.
weakest point in the anterior cranial base [30] (Fig. 3.14).
The AEA is a good endoscopic reference as it shows the
posterior endoscopic limit of the frontal recess at the fovea 3.5.3 First Olfactory Fiber and Nasal Branch
ethmoidalis. There is an average distance of 8.58 ± 5.56 mm of the Anterior Ethmoidal Artery
between the posterior border of the frontal sinus and the
AEA [35]. Extended drainage of the frontal sinus involves resection of
It lies at a mean distance of 21 mm from the axilla of the the floor of the frontal sinus between the lamina papyracea
middle turbinate and 10 mm from the ostium of the FS [34] and the middle turbinate (Draf IIa) or the nasal septum (Draf
(Fig. 3.15). IIb) anterior to the ventral margin of the olfactory fossa. Draf
There is a wide anatomical variation in the course of the type III drainage involves bilateral type IIb drainage with the
anterior ethmoid canal along the skull base. According to the addition of resection of the superior aspect of the nasal sep-
relationship with the anterior skull base, the AEA can run tum in the area adjacent to the frontal sinus floor. The poste-
attached to the skull base bone, can run freely along the eth- rior limit of the dissection remains anterior to the olfactory
moid, or in other cases the ethmoid canal may be connected fossa [36].
to the skull base through a bony mesentery. Conversely, the Thus, the first olfactory fiber has been proposed as a reli-
canal may be dehiscent, which increases the risk of bleeding able landmark to identify the posterior wall of the frontal
during the dissection [30]. sinus when performing a Draf III frontal sinusotomy or mod-
Care should be taken at this point as if transected at its ified Lothrop especially when carrying out an “Outside-In”
lateral portion, retraction may occur within the orbit leading frontal drill-out technique [37] (Fig. 3.16).
to a retroorbital hematoma which may increase the intraor- In addition, the first olfactory fiber marks the poste-
bital pressure that can result in an occlusion of the central rior limit of the superior septectomy during the procedure
32 I. M. Cánovas and E. G. Garrigós

a b c
Keros I: 1-3mm Keros II: 4-7mm Keros III: 8-16mm

d e

Fig. 3.13  Keros classification: 3 types of the lateral lamella [33]. (a) lateral lamella is very long (8-16 mm) producing a very deep olfactory
Type I. The lateral lamella is very short, rendering the olfactory fossa fossa (0.5%). (d, e) Coronal view of the perfunded specimen. Dotted
almost flat (1–3 mm) (26.3%). (b) Type II. The lateral lamella is longer, blue line: fovea ethmoidalis of the frontal bone; yellow dotted line
creating a moderately deep fossa (4-7 mm) (73.3%). (c) Type III. The vertical and horizontal lamella of the cribriform plate

(Fig. 3.17). However, this landmark presents some limita- 3.5.4 Frontal Beak (FB)
tions: it is not always easy to find as in some cases there
is fibrosis or anatomical distortion. Conversely, its expo- The FB is the midline bony thickening that made up the ante-
sure carries the potential risk of creating a CSF leak by rior limit of the frontal sinus ostium and the anterior limit of
opening the canal in which the fiber runs. Besides, the the FR. It is formed by the nasal and orbital process of the
ventral limit of the olfactory fossa often lies a few mil- frontal bone medially, the frontal process of the maxilla lat-
limeters anterior to the posterior wall of the frontal sinus erally, with a potential contribution from the nasal bone
[36]. Thus, recently the septal branch of the anterior eth- infero-anteriorly. “Frontal beak” is a non-anatomical term
moidal artery has been proposed as a safer landmark for that generally refers to the posterior aspect of the nasal pro-
identification of the posterior wall of the frontal sinus. cess of the frontal bone that can cause narrowing of the
The origin of these vessels lies in close proximity to the ostium [39].
posterior wall of the frontal sinus in the medial aspect of The thickness of the FB may vary eventually according to
the anterior ethmoidal roof, it runs within the lateral fis- the pneumatization of the ANC.  Wormald supports that a
sure of the cribriform plate (also known as criboethmoidal large ANC and frontal ethmoidal cell pneumatization will
foramen) a few millimeters anterior to the first olfactory often reduce the size of the beak, whereas the absence of
fiber. Given its localization, it represents a safer landmark these cells would produce a thick beak [24].
for the identification of the posterior wall of the FS. This The FB contributes to the anterior to posterior length of
enables the surgeon to maximize the drilling procedure by the frontal isthmus defined as the shortest length between the
opening the medial frontal drainage without risking iatro- most prominent portion of the FB and the anterior aspect of
genic CSF leaks [38]. the olfactory fossa. Sagittal reformatted CT images are
3  Frontal Sinus Classical and Endoscopic Anatomy 33

a b c d

e f g FS

AEA

Fig. 3.14  Anterior ethmoidal artery (AEA). (a–d) CT From the orbit, 40% of cases. (e) Endoscopic view: Right AEA after removing the
the AEA crosses the ethmoid labyrinth until it reaches the olfactory anterior wall of the bulla ethmoidalis. The posterior wall of the bulla is
fossa through the lateral lamella of the cribriform plate, forming the not opened. (f) Endoscopic view. Right AEA crossing from the orbit to
anterior ethmoid sulcus. It runs along the anterior skull base between the vertical lamella of the cribriform plate. Note the typical
the second and the third lamellas in 90% of cases. In the presence of posteroanterior and lateromedial direction. (g) Endoscopic view: Left
some variants (supraorbital and suprabullar cells (a)), it runs far from AEA.  There is an average distance of 8.58  ±  5.56  mm between the
the ethmoid roof surrounded by a mesentery with bone dehiscence in posterior border of the frontal sinus and the AEA

difficulty in dissecting the FR. Under normal conditions, the

wider the diameter, the easier the surgical dissection. At the
level of the frontal ostium, the mean anteroposterior distance
between the posterior edge of the FB and the anterior aspect
of the olfactory fossa is around 9–12 mm in the midline and
around 6 mm laterally. During Draf III procedure, the poste-
rior edge of the FB serves as a reliable landmark for avoiding
iatrogenic CSF leak during the superior septectomy [39].
Although it does not predict exactly the level of the skull
base, it lies anterior to the olfactory fossa. Thus, it seems to
be a safer landmark than the identification of the first olfac-
tory fiber during the superior septectomy.

3.5.5 Posterior Table of the Frontal Sinus

One of the most feared complications that can occur during

endoscopic frontal surgery is the creation of a CSF leak. The
Fig. 3.15  Relation between AEA and axilla middle turbinate. Right reported incidence of CSF leak following a modified Lothrop
nasal fossa. A complete ethmoidectomy has been performed. See the
AEA running along the skull base at a mean distance of 2 mm from the procedure oscillates between 1 and 6.6% [40, 41].
anterior attachment middle turbinate The Draf III procedure consists of the resection of the FS
floor bilaterally, the resection of the frontal intersinus sep-
tum, and the creation of a superior septal window (2 × 2 cm).
helpful in evaluating the size of the beak and its distance to This can be done through an “inside-out” traditional tech-
the skull base which has to be reviewed before surgery nique that consists of the initial identification of the frontal
(Fig. 3.18). These measurements usually offer the degree of recesses, followed by the bony removal in a medial direction.
34 I. M. Cánovas and E. G. Garrigós

a b c

*
* *

MT
MT MT

d e f

MT
MT

Fig. 3.16  First olfactory fiber and nasal branch of the anterior eth- through the roof of the nasal cavity (black arrow) and the first olfactory
moidal artery. (a) Endoscopic image showing the level of the posterior fiber in relation to the frontal sinuses. (d) Endoscopic image of a Draf
aspect of the superior septectomy. (b) The same as (a): (anterior to the IIb. (e) Endoscopic image of a Draf IIb procedure showing the first
first olfactory fiber: white asterisk). (c) Endoscopic image (Draf IIa) olfactory fiber on the left side in relation to the frontal sinus. (f)
showing the branch of the anterior ethmoidal artery as it courses Endoscopic image after completing a Draf III procedure

a b c

*
* *

d e

*
*
* *

MT
MT

Fig. 3.17  Superior septectomy during Draf III procedure. (a) Sagittal right nasal fossa. (d) Endoscopic image showing the posterior limit of
dissection. The green area shows the superior septectomy. (b) the septectomy. (e) Endoscopic picture after Draf IIb procedure. The
Endoscopic image showing the incision in the roof of the nasal cavity first olfactory fibers lie some millimeters anterior to the posterior wall
some millimeters anterior to the axilla of the middle turbinate. (c) First of the frontal sinus. White asterisk: First olfactory fiber; Black arrow:
olfactory fibers on the right and left side. The branch of the anterior Points the branch of the anterior ethmoidal artery as it courses through
ethmoidal artery can be identified as it courses through the roof of the the roof of the nasal cavity
3  Frontal Sinus Classical and Endoscopic Anatomy 35

a b c
* *
Nasal
Spine *

Nasal
Spine

Fig. 3.18  Frontal beak. (a) Sagittal dissection showing the FB (red superior septectomy. (d) CT scan in the sagittal axial and coronal plane
asterisk). (b) Sagittal view of the frontal bone showing the nasal spine of a specimen showing the anteroposterior distance between the
which forms part of the inferior aspect of the frontal sinus. (c) Sagittal posterior edge of the FB and the anterior aspect of the olfactory fossa
dissection showing the FB (red asterisk) as the posterior limit of the

Or, as an alternative, the “outside-in” technique that involves surgery in an oblique direction. Imaging techniques and
drilling down most of the frontal beak before the identifica- computer-guided navigation systems provide the surgeon
tion of the FRs [42]. with information about anatomical landmarks and variants
Whatever the case may be, the early identification of the for planning the surgery to avoid complications or failure. A
posterior wall of the frontal sinus during the opening of the clear 3D configuration of the frontal area before surgery is
floor of the sinus provides an essential landmark for safe sur- necessary to perform a safe and confident procedure.
gery as CSF leaks can occur mostly at the level of the olfac- Computer-guided navigation systems based on CT or MR
tory fossa and/or at the posterior frontal table of the FS. images use preoperatively acquired three-dimensional imag-
The anterior limit of the cribriform plate lies a few milli- ing data. 3D viewers are designed for navigation and visual-
meters anterior to the posterior wall of the frontal sinus. ization of multimodality and multidimensional images and
Therefore, once the posterior wall of the frontal sinus and the offer all modern rendering modes (multiplanar reconstruc-
anterior limit of the cribriform plate have been identified, the tions, surface rendering, volume rendering, and maximum
dissection can be extended laterally. intensity projection). Otherwise, insecurity in the frontal
recess will often either result in inadequate surgery with
functional failure or an increase in the risk of orbit, brain, or
3.6 Conclusions vascular injury.

In summary, surgery in the FR and FS remains a challenge Acknowledgments To the anatomy laboratory of the Faculty of
because of the complex and variable anatomy, the important Medicine from the Miguel Hernández University of Elche (Alicante),
for their great collaboration and help to prepare the specimens for
structures that surround the drainage pathway, and the ana- dissection.
tomical disposition that demands the surgeon to perform the
36 I. M. Cánovas and E. G. Garrigós

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 Indications of Frontal Sinus Surgery
4
Claudia González and Claudio Callejas

4.1 Introduction symptoms must be accompanied by either endoscopic signs

of nasal polyps or inflammation in the middle meatus and/or
The indications for frontal sinus surgery include a broad CT mucosal changes within the ostiomeatal complex or
spectrum of different pathologies. The most common is sinuses [1].
chronic rhinosinusitis, but neoplastic lesions (benign and Patients who fail disease control after receiving appropri-
malignant) and skull base defects (e.g., CSF leaks and fron- ate medical management (Table  4.1) should be considered
tal fractures) are also on the list. for surgery.
The election of medical treatment and the need for sur- The EPOS 2020 guidelines propose to classify CRS based
gery, as well as the type of procedure, may depend on several on the extension of disease (localized or diffuse) and if there
factors, e.g., the nature and extension of the patient’s disease, is an identifiable secondary cause or not [1]. Further classifi-
symptoms, the particular anatomy of the frontal recess, the cation is based on endotypes: type-2 (inflammation with pro-
surgeon’s experience and skills, and patient preferences. duction of the cytokines (IL-4, IL-5, and IL-13) [2] and
Given all these variables, different approaches to solving the non-type-2 (type 1: expression of the cytokines interferon
same case with success are possible. Although endoscopic (IFN), and IL-12; type 3 inflammation, with elevated levels
sinus surgery is considered the gold standard for the surgical of IL-17 and IL-22) [2].
treatment of the sinuses, open approaches still have a role in
selected cases. 4.2.1.1 Localized Frontal CRS
This chapter aims to overview the most common frontal Primary localized disease involving the frontal sinus can be
sinus surgery indications and discuss critical factors to have subclassified into allergic fungal rhinosinusitis AFRS (type-­
in mind when choosing the surgical approach to treat them. 2) (Fig. 4.1), and isolated sinusitis (non-type 2) (Fig. 4.2). In
Other chapters will describe in detail the different surgical both conditions, surgery is indicated. Localized AFRS is
techniques available. likely to progress with time and unlikely to be controlled
only with medical therapy. Primary localized CRS, usually
secondary to an anatomic cause, doubtful to resolve sponta-
4.2 Inflammatory Diseases neously, could evolve to a mucocele formation [3].
Isolated frontal CRS can be treated with endoscopic sinus
4.2.1 Chronic Rhinosinusitis (CRS) surgery, clearing the cells of the frontal recess (grade 1, 2, or
3 procedure) (for detailed classification of frontal sinus inter-
According to EPOS 2020 guidelines, CRS is defined as ventions, review Chap. 6). However, in the presence of new
inflammation of the nose and the paranasal sinuses lasting bone formation or scarring tissue in the frontal recess, bone
for more than 12 weeks. It is characterized by the presence of removal procedures (grade 4, 5, or 6) may be required to get
two or more symptoms, one of which should be either nasal a wide opening of the affected sinus and secure long-term
blockage, obstruction, congestion, or nasal discharge (ante- patency.
rior/posterior nasal drip), associated or not with facial pain/ Isolated frontal sinusitis in the absence of dehiscence at
pressure, with or without reduction or loss of smell. These the posterior table of the frontal sinus, skull base, or orbital
rim, without new bone formation, can be treated with a fron-
tal sinus balloon dilatation (for details, see Chap. 9).
C. González · C. Callejas (*) Secondary localized frontal CRS includes the diagnosis
Department of Otolaryngology, Pontificia Universidad Católica de
of a fungal ball. In this case, the CT scan usually shows het-
Chile, Santiago, Chile

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 37

D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_4
38 C. González and C. Callejas

Table 4.1  EPOS 2020: Assessment of current clinical control of CRS (in the last month)
Controlled (all of the Partly controlled (at least one
following) present) Uncontrolled (3 or more present)
Nasal blockage Not present or not Present on most days of the weekb Present on most days of the weekb
bothersomea
Rhinorrhea/postnasal Little and mucousa Mucopurulent on most days of the Mucopurulent on most days of the weekb
dripc weekb
Facial pain/pressurec Not present or not Present on most days of the weekb Present on most days of the weekb
bothersomea
Smellc Normal or only slightly Impairedb Impairedb
impaireda
Sleep disturbance or Not presenta Presentb Presentb
fatiguec
Nasal endoscopy Healthy or almost healthy Diseased mucosad Diseased mucosad
(if available) mucosa
Rescue treatment Not needed Need of 1 course of rescue Symptoms (as above) persist despite rescue
(in the last 6 months) treatment treatment(s)
CRS chronic rhinosinusitis, VAS visual analog scale
a
For research VAS ≤5
b
For research VAS >5
c
Symptoms of CRS
d
Showing nasal polyps, mucopurulent secretions, or inflamed mucosa

erogeneous opacities within the frontal sinus (Fig.  4.3). 4.2.1.2 Diffuse CRS
Frequently, discrete and very dense areas (even metallic den- Regarding chronic rhinosinusitis’s surgical treatment, over
sities) are seen. In advanced cases, bone erosion and remod- the years, the decision to perform a procedure involving the
eling can be observed. If the exact nature of the disease is not frontal sinus and the extent of the surgery has been debated
precise, an MRI may clarify the diagnosis. A fungal ball is [6]. They range from minimally invasive or non-surgical
characterized by T1 scans showing central hypointensity and manipulation of the frontal recess or frontal sinus to extended
T2 scans with a signal void [4] (Fig. 4.4). endoscopic procedures as grade 6 (Draf III) [7].
Endoscopic sinus surgery is the treatment of choice Before discussing frontal sinus surgery in primary diffuse
(Fig. 4.5). Surgery of asymptomatic fungal ball is generally CRS, it is essential to consider the current understanding of
recommended unless other conditions such as age and its pathophysiology. Initially, endoscopic sinus surgery was
comorbidities contraindicate the procedure [4]. Particular conceived based on Messerklinger’s studies [8] to treat sinus
attention and immediate surgery should be considered if the blockage, with the hypothesis that clearing the obstruction of
patient’s immunological status may put him at risk of inva- the common drainage pathway restores function by improv-
sive fungal disease, such as patients undergoing a solid organ ing ventilation and allowing normal mucociliary clearance.
or bone marrow transplant, or other immunosuppressive Today, CRS is conceived as a disease of the mucosa of the
disorder. sinuses. Increasing evidence supports that inflammatory load
The extent of the surgery will vary according to the fron- is the most important predictor of long-term outcomes.
tal recess anatomy. The goal is to achieve access wide Cytokines and pro-inflammatory mediators tend to increase
enough to remove all the fungal debris from the frontal sinus over time, self-perpetuating mucosal disease, especially in
to avoid recurrence. Hence in cases of wide frontal ostium some type-2 phenotypes [2, 5, 9]. Nowadays, surgery aims
diameter, clearing all the cells from the frontal recess may not merely to release obstruction to the sinuses drainage
be enough to remove all the fungal content within the frontal pathways, but more importantly, remove the inflammatory
sinus with the aid of thorough irrigation into the sinus. mediators present in polyps, mucus secretions, and disease
However, in cases with narrow frontal ostium diameter, a mucosa (without leaving exposed bone). By widening the
bone removal procedure may be necessary to create a wide sinus’s openings, surgery also allows penetration of rinses
enough access into the frontal sinus [5]. Alternatively, com- and topical therapies to control mucosal inflammation. These
bining a cell clearing procedure with a frontal sinus trephine concepts justify more radical surgeries to achieve these
will ensure the frontal sinus’ clearing. Again, attention to objectives in patients with severe type-2 phenotypes (e.g.,
the presence of osteoneogenesis in the frontal recess is AERD) [9].
essential, which may determine the necessity of a bone To date, there is little evidence supporting the outcomes
removal procedure. of the minimally invasive sinus technique regarding quality-­
4  Indications of Frontal Sinus Surgery 39

a b

c d

e f

Fig. 4.1  Allergic fungal rhinosinusitis. (a) Coronal. (b) Axial CT scan sinuses. (e) Coronal plane T2 weighted image showing central signal
(bone window). (c) Coronal. (d) Axial CT scan (tissue window). void. (f) Coronal plane T1 weighted image
Observe the heterogeneous opacification and expansion of the right
40 C. González and C. Callejas

a b

c d

Fig. 4.2  Isolated left frontal sinus CRS. (a, b) Coronal. (c) Axial. (d) Parasagittal CT scan. Observe the cells well-pneumatized into the frontal
sinus, obstructing the drainage pathway

of-­life and revision rates. [7]. According to Chiu et al. [10], Although not widely accepted, it has been proposed that
frontal sinus surgery failure was attributed to residual ante- bone removal approaches to the frontal sinus, mainly Draf III
rior ethmoid partitions in 79%, retained uncinate process in (grade 6), are suitable as primary surgical procedures when
38.8%, and a lateralized middle turbinate in 35.8%. treating diffuse CRS with severe type-2 phenotypes, like an
Nowadays it is widely accepted that patients with primary aspirin-exacerbated respiratory disease (AERD). The ratio-
diffuse CRS who fail appropriate medical management and nale supporting this idea relies mainly on the inflammatory
have disease in the frontal recess require frontal sinus sur- load hypothesis [9]. Radical surgery has been shown to have
gery, with clearance of all of the cells in the recess, even if better outcomes when treating diffuse CRS with severe
the frontal sinus itself has little or no evidence of disease on type-2 phenotypes [9]. Moreover, topical therapy and nasal
CT scans (Fig. 4.6). irrigation are critical for long-term disease control. Cadaveric
4  Indications of Frontal Sinus Surgery 41

a b

c d

Fig. 4.3  Paranasal sinus CT scan. Left frontal sinus fungal ball. (a) areas in the ethmoid (white arrow). (c) Parasagittal plane showing a
Coronal plane. Note the presence of dense material in the center of the thinned and displaced posterior table (dotted arrow). (d) Axial plane:
fungal ball (white arrow). (b) Coronal plane: observe the very dense Observe the fungal ball protruding into the orbit

and live patients studies demonstrated that sinus lavages improvement was more remarkable in grade 6 patients, as
mostly reach the frontal sinuses when a grade 6 procedure their basal disease was more severe than patients undergoing
(Draf III) was performed [11–13]. A recent study evaluating grade 5 surgery [14].
the quality-of-life after grade 5 (Draf IIB) or 6 (Draf III) pro- Unfortunately, no randomized trials comparing primary
cedures in patients, including type 2 and non-type-2 pheno- grade 6 procedures (Draf III) with others less extended for the
types, found that both groups benefit from the surgery. The initial surgery of type-2 patients are available. One meta-­
42 C. González and C. Callejas

a b

c d

Fig. 4.4  Paranasal sinus MRI of the case presented in Fig. 4.3. (a) Coronal plane and (c) Axial plane T1 weighted images: observe the central
hypointensity. (b) Coronal plane. (d) Axial plane T2 weighted images: observe the central signal void (white arrow)

analysis showed that grade 6 is an effective salvage procedure when anatomy (e.g., narrow frontal sinus ostium or a signifi-
for refractory frontal sinusitis and that in AERD and asthma, cant number of cells extending high into the frontal sinuses)
Draf III was associated with a reduced incidence of reopera- precludes adequate clearance of frontal sinuses inflammatory
tion and increased symptom improvement [15]. In our opin- load (polyps and tenacious secretions) (Fig. 4.7).
ion, primary Draf III procedure might be considered as an The final decision should be accompanied by a discussion
option in patients with severe type-2 phenotypes (AERD) with the patient regarding the pros and cons of a grade 6 or
4  Indications of Frontal Sinus Surgery 43

abscesses (group III) can usually be drained endoscopically.

Orbital abscesses (group IV) may require the assessment of
an oculoplastic surgeon. Performing frontal sinus surgery on
a patient with acute sinusitis can be quite challenging because
of significant bleeding from the inflamed mucosa. If the sur-
geon does not feel comfortable performing frontal sinus sur-
gery in this scenario, a frontal trephine would be considered
to easily drain the sinus. Importantly, an intracranial compli-
cation should be ruled out when an orbital complication is
diagnosed.
Regarding intracranial complications, it is the chapter
authors’ philosophy to always consider surgery in the initial
management, if the patient’s condition allows it, along with
wide spectrum intravenous antibiotics that can penetrate the
blood–brain barrier (e.g., ceftriaxone plus metronidazole).
Neurosurgical assessment is required as the patient may
need concomitant surgical treatment of the intracranial
Fig. 4.5  Endoscopic view of the case shown in Figs. 4.3 and 4.4. 45° complication. Again, all of the involved sinuses need to be
scope, frontal sinus widely opened, observe the characteristic grayish
addressed.
material (white arrow) corresponding to the fungal ball inside the fron-
tal sinus Pott’s puffy tumor (PPT) represents a rare complication
of frontal sinusitis. It is an osteomyelitis and subperiosteal
abscess of the anterior table of the frontal sinus [18, 19].
lesser extent procedure (Chaps. 12–13), including the reop- Clinical presentation is characterized by inflammatory signs
eration rate and complications (Chap. 29). in the forehead (erythema, edema, pain, fluctuating mass)
Regarding secondary diffuse CRS, before considering and fever. Intracranial complications coexist in around 29%
surgery, medical management of the sinonasal disease should of adult patients [20], hence imaging of the brain is required
consider treating the underlying condition. (CT scan with contrast and/or MRI) (Fig.  4.8). Treatment
consists of intravenous broad-spectrum antibiotics and surgi-
cal drainage of the frontal sinus when there is an associated
4.2.2 Complications of Rhinosinusitis intracranial complication or lack of response to antibiotics
after 24–48 h of treatment. If there is osteoneogenesis in the
Acute bacterial rhinosinusitis complications are rare but still frontal recess (frequently in adults) that would require a bone
occur, most commonly in children and immunocompromised removal procedure (grade 5 or 6) to drain the sinuses, the
patients. The frontal sinus is usually involved in older chil- surgeon can consider treating the infection first with antibiot-
dren as it is poorly developed in patients younger than ics and trephination before performing any of these techni-
10 years. There seems to be a higher probability of develop- cally demanding endoscopic procedures.
ing intracranial complications in young adolescent males,
who present with frontal sinus involvement [16].
Not every orbital complication requires surgical treat- 4.2.3 Mucocele
ment. In 1970, Chandler et al. [17] proposed a classification
for orbital complications in acute sinusitis that is still widely A mucocele is a slow-growing expansile epithelial-lined cys-
used nowadays, Table  4.2. Group I (preseptal cellulitis) is tic mass often associated with bone erosion. They originate
treated only with antibiotics. The other groups will likely from obstruction of sinus ostia and hence are filled with
require surgery. Surgery must aim to drain all of the compro- mucus [21]. The frontal and ethmoid sinuses are the most
mised sinuses. In group II, when vision is not impaired, it is commonly affected [22].
reasonable to evaluate the response to wide spectrum intra- Endoscopic marsupialization with preservation of the lin-
venous antibiotics (e.g., ceftriaxone plus clindamycin) with ing mucosa is the treatment of choice. Open approaches still
close observation for 24–48  h before deciding on surgery. have a role in managing far lateral frontal mucoceles in well-­
This conduct is also possible in small children (under 9 years pneumatized sinuses, as reaching the lesion endoscopically
old) with small subperiosteal abscesses. Subperiosteal could be quite challenging [21]. Giant frontal mucoceles
44 C. González and C. Callejas

a b

c d

Fig. 4.6  Paranasal sinus CT scan. Diffuse CRS. (a) Coronal plane. (b) Parasagittal plane of the left nasal cavity. (c) Axial plane. (d) Parasagittal
plane of the right nasal cavity. Both frontal sinuses are clear, although diffuse inflammation is observed bilaterally at the frontal recess

may warrant an open or combined approach due to various cedures involving bone removal. In the case of frontal recess
concerns, including frontal lobe displacement, size, and osteoneogenesis, an endoscopic bone removal procedure
rapid decompression of the intracranial content [23]. Surgical (grade 5 or 6) may be necessary to properly marsupialize the
management will be discussed in extension in Chap. 25. It lesion and avoid stenosis leading to the closure of the frontal
ranges from cell clearing procedures to more extensive pro- sinus drainage (Fig. 4.9).
4  Indications of Frontal Sinus Surgery 45

a b

c d

e f

Fig. 4.7  Diffuse AERD (type-2) CRS. (a) Observe the polyps reaching CT scan. (e) Follow-up endoscopic exam after surgery (left nasal cav-
the nasal vestibule bilaterally. (b, c) Coronal CT scan. Observe ity). (f) Left frontal sinus widely opened
the complete opacification of the nose and sinuses. (d) Parasagittal
46 C. González and C. Callejas

Table 4.2  Orbital complications of acute rhinosinusitis. Chandler while bigger osteomas will be better treated with broad
classification [17]
exposure as a grade 6 procedure (Fig. 4.10).
Group Complication Nowadays, thanks to advances in instrumentation and
Group I Preseptal cellulitis surgical techniques, complex osteomas extending into the
Group II Orbital cellulitis
orbit can be resected fully endoscopically. Using a cavitation
Group III Subperiosteal abscess
technique to drill out the core of the tumor, it is feasible to
Group IV Intraorbital abscess
Group V Cavernous sinus thrombosis
obtain a thin, hollowed bony shell that can be gently frac-
tured and then removed transnasally, leaving clear margins
[25] (Figs. 4.11 and 4.12).
With large, complex lesions filling a significant portion of
the frontal sinus, a time-consuming, technically demanding
endoscopic resection must be weighed against a much more
straightforward and faster open approach. In a systematic
review [26], Watley et al. proposed a classification to assist
the surgeon in selecting the surgical approach to resect fron-
tal sinus osteomas (Table  4.3). Grade A osteomas can be
removed endoscopically. Grade B tumors can be resected
endoscopically but may require an extended endoscopic
approach depending on the surgeon’s expertise and the
patient’s anatomy. Grade C lesions are broad-based tumors
with extensive floor attachment or vast extra sinus extension;
these patients almost universally require an open approach.

4.3.1.2 Fibrous Dysplasia (FD)

FD is a benign idiopathic skeletal disorder characterized by
Fig. 4.8  Pott’s puffy tumor. Parasagittal CT scan. Observe the frontal replacement and expansion of medullary bone by disorga-
swelling caused by the subperiosteal abscess (white arrow), complete nized fibro-osseous tissue, which may produce bony defor-
opacification of the frontal sinus (asterisk) and an epidural abscess adja-
cent to the posterior table (black arrow). Image courtesy of Dr. Fabian
mity, and morbidity resulting from nasal or sinus obstruction
A. Rubio. Hospital La Florida, Chile (Fig. 4.13). This entity should be considered in the differen-
tial diagnosis of patients presenting with proptosis, visual
disturbance, and bony frontal-orbital swellings. CT scan
4.3 Sinonasal Tumors shows a characteristically ground glass appearance; other
features include sclerotic and lytic areas [27]. FD can be suc-
4.3.1 Benign Lesions of the Frontal Sinus cessfully treated with a bone removal (grade 5 or 6) proce-
dure if it obstructs the frontal sinus drainage pathway [28].
4.3.1.1 Osteomas
Osteomas are the most common benign sinonasal tumor, 4.3.1.3 Inverted Papilloma (IP)
usually found in the frontal and ethmoid sinuses. They are This benign tumor accounts for approximately 0.5–4% of all
slow-growing bony tumors. Although they are frequently sinonasal neoplasms. It is characterized by a tendency to be
incidentally found in asymptomatic patients, they can cause locally aggressive, a propensity to relapse when removal is
sinus obstruction leading to recurrent infections, barotrauma, not thorough, and a potential for malignant transformation in
mucocele formation, or cosmetic deformities [24]. squamous cell carcinoma (SCC) in 9% of the cases, accord-
Asymptomatic osteomas that do not grow or block the ing to a systematic review [29].
sinuses’ drainage can be conservatively managed with obser- Preoperative image analysis is fundamental for surgical
vation. Indications for surgery include symptomatic osteo- planning. A preoperative biopsy or contemporary frozen
mas, or asymptomatic overt growing tumors (Fig. 4.11). As sections during surgery should be obtained to confirm the
periodic imaging follow-up is required to determine growth, diagnosis and exclude synchronous SCC, especially when
MRI without contrast can be considered to avoid significant there is bone destruction on CT scans. Assessing the
radiation exposure. tumor’s extension and identifying the attachment site on
The ability to remove a frontal sinus osteoma endoscopi- images is necessary to plan surgical removal. On CT scans,
cally depends on the size and location of the tumor. Smaller the attachment site can appear as a hyperostotic area
ones can be easily removed with less aggressive approaches, (Fig. 4.14).
4  Indications of Frontal Sinus Surgery 47

a b

c d

Fig. 4.9  Paranasal sinus CT scan. Bilateral frontal sinus mucocele. neogenesis in both frontal recesses. (c) Parasagittal plane showing a
(a, b) Coronal plane: observe the expansive round cysts (asterisk) that wide AP diameter of the frontal sinus. (d) Axial plane. Note the thinned
have eroded the orbital wall, protruding into the orbit. Note the osteo- posterior table

A gadolinium-enhanced MRI is helpful to differentiate Fundamental principles in the surgical treatment of IP are
secretions from IP. MRI is essential when assessing frontal complete removal of the tumor and drilling of the attachment
sinus opacification in the presence of inverted papilloma. site. If the latter is not feasible, removing the mucoperios-
The extent of surgery required to remove it may vary signifi- teum and cautery of this region should decrease recurrence
cantly depending on if the IP involves the frontal sinus or not chances. Inverted papillomas arising from the frontal sinus
(especially if the attachment site is inside the frontal sinus) can be frequently removed with an endoscopic approach but
(Fig. 4.15). will often require broad exposure employing a Draf III pro-
48 C. González and C. Callejas

a b

Fig. 4.10  Frontoethmoidal osteoma, coronal CT scan. (a) Preoperative. duced nor injury to the trochlea of the superior oblique muscle. The
(b) After endoscopic resection. Through a grade 6 procedure (Draf III) patient did not present diplopia. A small remnant of the osteoma was
it was possible to cavitate the core of the osteoma to then fracture the left attached to the skull base in the right frontal sinus, which has been
bony shell into the nasal cavity applying pressure with the thumb in the stable over time. Image A was reproduced with permission from Rev.
medial canthal region of the eye. No breach in the periorbita was pro- Otorrinolaringol. Cir. Cabeza Cuello 2019; 79: 50–58

cedure [30]. However, for very pneumatized frontal sinuses sized that prior incomplete surgery favors recurrence with
with an attachment far lateral or superior, an external or a multiple attachment sites [32, 33]. The IP recurrence rate
combined approach will be required (Fig.  4.16). Thus, the varies from 6% [31] and 20% [33] for frontal sinus localiza-
surgeon must be prepared to convert to an external approach tion. The need for long-term follow-up in these patients is
according to the intraoperative findings [31]. mandatory, as recurrence has been reported for as long as
The following findings have been proposed as contraindi- 6 years post-op [33].
cations for fully endoscopic resection of a frontal IP: a small
anteroposterior diameter of the frontal sinus (<1  cm) and
small interorbital distance; erosion of the posterior wall of 4.3.2 Malignant Neoplasm
the frontal sinus with intracranial extension; extension of the
lesion through the anterior frontal plate; massive lateral Frontal sinus malignancy is rare, comprising less than 2% of
supraorbital attachment of the lesion in laterally pneuma- all sinonasal malignancy cases [34]. In general, open
tized frontal sinus; attachment of the tumor to the anterior approaches are required to treat them, usually combined with
wall or the upper half of the posterior wall of the frontal endoscopic sinus surgery to achieve total removal of a sino-
sinus; massive involvement of the mucosa of the frontal nasal tumor extending into the frontal sinus [35, 36].
sinus and supraorbital cell; histological evidence of SCC in The following sinonasal malignancies can potentially
IP at preoperative biopsies or intraoperatively with frozen involve the frontal sinus by direct extension or less frequently
sections; the presence of abundant scar tissue from previous as the primary site of the tumor: squamous cell carcinoma,
surgery or relevant post-traumatic anatomic changes of the sinonasal adenocarcinoma, olfactory neuroblastomas (esthe-
frontal bone [31]. Surgical treatment will be discussed in sioneuroblastoma), and sinonasal undifferentiated carci-
detail in Chap. 27. noma, within others.
Resecting an IP from the frontal sinus requires a high For tumors, like a esthesioneuroblastoma, that require
level of expertise. It is essential to have this in mind as the endoscopic resection of the cribriform plate, a Draf III pro-
first surgery is the best chance to cure a patient. Revision cedure is mandatory to adequately expose the most anterior
surgery is, in general, more complex and has higher recur- part of the plate and the crista Galli to perform an adequate
rence rates (Figs. 4.17 and 4.18). It has also been hypothe- resection (Fig. 4.19).
4  Indications of Frontal Sinus Surgery 49

a b

c d

Fig. 4.11  Paranasal sinus CT scan. Large frontoethmoidal osteoma. (a, b) Coronal plane: osteoma extending into the left orbit and encasing the
anterior ethmoid artery (AEA: white arrow). (c) Parasagittal plane of the left nasal cavity (AEA: black arrow). (d) Axial plane

4.4 Skull Base Defects tal [37]. If spontaneous CSF is diagnosed, idiopathic
intracranial hypertension must be ruled out.
4.4.1 Frontal Sinus Cerebrospinal Fluid An endoscopic exam may not reveal the CSF leak site, but
(CSF) Leak it is necessary to assess the patient’s anatomy and determine
potential donor structures for repair, as a mucosal flap. This
CSF leak affecting the frontal sinus is a rare condition. It can step is of great importance in patients with an iatrogenic CSF
be solely or associated with meningoencephalocele or leak from previous surgery, where turbinates removal or sep-
meningocele. The etiologies include spontaneous CSF, iatro- tal perforations can modify the reconstruction strategy. Fine-­
genic, secondary to trauma or tumor expansion, and congeni- cut CT scans are crucial to review the anatomy and establish
50 C. González and C. Callejas

a b

c d

Fig. 4.12  Postoperative paranasal sinus CT of the case shown in ostium diameter. The anterior ethmoidal artery was identified within the
Fig. 4.11. (a, b) Coronal plane. (c) Axial plane. (d) Parasagittal plane of osteoma and cauterized before sectioning it to remove the osteoma
the left nasal cavity. The osteoma was entirely removed by an endo- encasing it. There was no damage to the skull base or breach of the
scopic approach using a cavitation technique. An extended procedure periorbita
was not required to remove the frontal portion due to the wide frontal

Table 4.3  Frontal sinus osteoma grading system (Watley et al.) [26]
Osteoma grade A B C
Attachment Simple stalk or broad Broad Broad or completely filling sinus
Floor attachment Absent Minimum Extensive when present
Anatomy Favorable Unfavorablea Unfavorablea
Extra sinus involvement None Minimum Extensive extra sinus involvementb
Unfavorable anatomy: narrow anteroposterior diameter <1 cm, narrow interorbital distance
a

Beyond a simple orbital or intracranial extension

b
4  Indications of Frontal Sinus Surgery 51

a b

c d

Fig. 4.13  Paranasal sinus CT.  Diffuse CRS and fibrous dysplasia of ethmoid artery. (c) Parasagittal plane of the right nasal cavity. The
the right anterior ethmoid. (a, b) Coronal plane. Observe the lesion in lesion narrows the frontal sinus drainage pathway without causing dis-
continuity with the lateral lamella and skull base, close to the anterior ease inside the frontal sinus. (d) Axial plane

the location of the CSF leak and the size of the defect. Brain clearing the cells from the recess. When the leak is located at
MRI helps determine the existence of meningocele or menin- the frontal sinus’s posterior table, a broad exposure (grade 5
goencephalocele and helps rule out vessels within the defect. or 6 procedure) will be required to comfortably access and
Endoscopic surgical repair is suitable in many cases, with repair the defect. In selected cases, the osteoplastic approach
a success rate ranging between 91.9% [38] and 97.3% [39]. still would be necessary [37, 40]. Maintenance of frontal
Small skull base defects in the fovea ethmoidalis in the fron- sinus patency must always be in mind when repairing a CSF
tal recess region can be repaired, exposing the defect by just leak (Chap. 24).
52 C. González and C. Callejas

a b

c d

Fig. 4.14  Inverted papilloma of the right nasal cavity. (a) Endoscopic view of the right nasal cavity showing an IP without evident attachment site.
(b, c) Coronal plane CT scan. (d) Parasagittal plane of the right nasal cavity. Note the diffuse opacification of the frontal sinuses and frontal recess

4.4.2 Fractures of the Frontal Sinus If the fracture compromises the frontal sinus outflow
patency and the bone displacement obstructs the frontal
Frontal sinus fractures can be life-threatening and compro- recess, an endoscopic approach is indicated. A more conser-
mise intracranial, facial, and orbital structures, with a high rate vative approach would be favored if the frontal sinus outflow
of mortality (25%) and neurological morbidity (42%) [41]. tract is patent, with multiple studies demonstrating good out-
Treatment of these fractures or their complications with comes with observation alone [43]. These cases require a
endoscopic sinus surgery has reduced the need for oblitera- strict follow-up with a CT scan at 6  weeks and after
tion and cranialization of the frontal sinus [42]. 12 months. Subsequent identification of drainage obstruction
4  Indications of Frontal Sinus Surgery 53

a b

Fig. 4.15  Paranasal sinus MRI of the case described in Fig. 4.14. (a) signal of the mucus above the IP. Image (a) was reproduced with per-
Coronal. (b) Parasagittal T2 weighted images. Observe the IP filling mission from Rev. Otorrinolaringol. Cir. Cabeza Cuello 2019; 79:
both frontal sinuses (black arrows) in contrast with the hyperintense 50–58

a b

Fig. 4.16  Paranasal sinus CT scan. Limits of endoscopic frontal sinus approach. Green areas represent regions that would need a combined or
surgery. (a) Coronal plane. (b) Parasagittal plane. Schematic view open approach
showing in black the areas that a surgeon can reach from the endoscopic
54 C. González and C. Callejas

a b

c d

Fig. 4.17  Paranasal CT scan. IP recurrence at the frontal T level. (a) Coronal plane. (b) Parasagittal plane. (c) Axial plane. (d) Endoscopic view
of the recurrence, a sample for biopsy was taken

warrants an endoscopic procedure to restore clearance and sinus opacification, or mucocele formation detected during
avoid mucocele formation. follow-up. Severe displacement of the posterior table war-
Posterior table fractures with mild or moderate displace- rants the consideration of cranialization [42] (Chap. 24).
ment can also be treated endoscopically if persistent CSF Anterior table fractures need correction or camouflage when
leak (lasting more than 7 days after trauma). Other indica- significant bone displacement (greater than 4 mm) compro-
tions for endoscopic resolution include persistent frontal mises the cosmetic outcome (Fig. 4.20).
4  Indications of Frontal Sinus Surgery 55

a c

Fig. 4.18  Same patient described in Fig. 4.17. Intraoperative findings Coronal CT scan showing the region of the left lateral lamella where the
confirmed the attachment of the inverted papilloma within the pneuma- tumor was attached. (c) Endoscopic view during the surgery. After the IP
tized crista galli and the lateral lamella of the cribriform plate. (a) Axial was removed, the attachment site at the lateral lamella was drilled with a
CT scan, the red circle shows the opacified pneumatized crista galli. (b) diamond burr. After 5 years of follow-up, no recurrence has been observed

a b

Fig. 4.19  Esthesioneuroblastoma of the right nasal cavity. (a) CT scan arrow). (d) Coronal CT scan after tumor removal with a bilateral tran-
coronal plane showing the right nasal cavity occupied by the tumor. (b) scribriform approach. Draf III was performed to access the most ante-
Coronal MRI T1-Gadolinium image. Observe a small portion of the rior part of the cribriform plate and crista galli (asterisk). Images a and
tumor in the anterior cranial fossa (white arrow). (c) Parasagittal T2 b were reproduced with permission from Rev. Otorrinolaringol. Cir.
weighted image. Showing the intracranial tumor extension (white Cabeza Cuello 2017; 77: 57–62
56 C. González and C. Callejas

c d

Fig. 4.19 (continued)

5. Bernardini E, Karligkiotis A, Fortunato S, Castelnuovo P, Dallan

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17. Chandler JR, Langenbrunner DJ, Stevens ER.  The pathogen-

31. Pietrobon G, Karligkiotis A, Turri-Zanoni M, Fazio E, Battaglia
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 Pre-operative Medical Management
5
Yvonne Chan and Alkis J. Psatis

5.1 Management of Co-morbidities The mechanism by which steroids reduce blood loss
remains unknown; however, it is postulated that their benefi-
Prior to endoscopic sinus surgery, it is important that patients cial effects may be in part related to their potent anti-­
undergo a comprehensive history and examination to iden- inflammatory action, but also their ability to potentiate the
tify medications or co-morbidities that may directly or indi- effects of adrenalin on smooth muscle, possibly by prolong-
rectly increase the risk of intra-operative bleeding. Aside ing topical vasoconstriction.
from ceasing anti-coagulant therapy where it is medically
appropriate to do so, patients should also be educated to
avoid over-the-counter medications and supplements that 5.2.1 Intranasal Corticosteroids
may increase the risk also such as NSAIDs, ginger, ginkgo
biloba, garlic, fish oil, and St John’s Wort to name just a few Intranasal corticosteroids (INCs) remain the first line of
[1]. Uncontrolled hypertension is also a risk factor for exces- treatment in patients with chronic rhinosinusitis (CRS) [2].
sive intra-operative bleeding and should be appropriately Their role pre-operatively has been less well studied; how-
managed prior to surgery. With increasing rates of obesity in ever, emerging evidence suggests that they may improve the
the Western World, obstructive sleep apnea (OSA) is com- surgical field by reducing intra-operative bleeding.
monly seen in patients undergoing endoscopic sinus surgery. To date there are only a few published studies investigat-
OSA, especially when untreated, can increase peri-operative ing the effects of INCS on bleeding during endoscopic sinus
bleeding through direct vasodilation due to CO2 retention, as surgery in CRS patients. In 2010, Albu et al. randomized 70
well as through its effects on mean arterial blood pressure CRS patients with and without polyps to receive a placebo or
and blood pressure lability. mometasone furoate (MF) nasal spray 200 μg twice daily for
a period of 4 weeks pre-operatively. The MF-treated group
demonstrated a significantly decreased total blood loss
5.2 Corticosteroids (mean difference of 27.7 ml), operating time (mean differ-
ence of 11.2  min) as well as improved endoscopic vision
Studies suggest that pre-operative use of intranasal and oral during endoscopic sinus surgery (ESS) compared to the pla-
corticosteroids may reduce intra-operative bleeding and in cebo group [3]. A more recent study of 97 patients was con-
doing so improve the surgical field and post-operative ducted by Tirelli et al.: patients regularly using INCS prior to
outcomes. surgery were compared to a non-INCS user group, with
intra-operative blood loss and operative time assessed. They
Y. Chan (*) observed no significant difference in average blood loss in
Department of Otolaryngology - Head and Neck Surgery, mL and operative time between the groups but interestingly
St. Michael’s Hospital, Toronto, ON, Canada the Boezaart bleeding scores were significantly higher in the
Department of Otolaryngology - Head and Neck Surgery, INCS group [4]. A systematic review and meta-analysis
University of Toronto, Toronto, ON, Canada study by Pundir et al. supports the use of topical corticoste-
e-mail: [email protected]
roids pre-operatively given the overall finding of decreased
A. J. Psatis blood loss, improved surgical field, and reduced operative
Department of Otolaryngology - Head and Neck Surgery, Queen
time [5]. In concordance with the recommendations of the
Elizabeth Hospital, Adelaide, SA, Australia
European Position Paper on Rhinosinusitis and Nasal Polyps
Department of Surgery, Faculty of Medicine, University of
2020 (EPOS 2020) EPOS steering group and the recently
Adelaide, Adelaide, SA, Australia

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 59

D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_5
60 Y. Chan and A. J. Psatis

updated International Consensus in Allergy and Rhinology

(ICAR) document (RS-ICAR-2021), we advise the use of
INCS before ESS [2, 6].

5.2.2 Systemic Corticosteroids

Four double blind placebo-controlled trials assessed the

effects of pre-operative systemic corticosteroids on sinus
surgery [7–10]. The doses used varied from 30 mg of predni-
sone for 5 days prior to surgery in 2 studies [7, 8], a 10 day
tapering prednisone course (1 mg/kg for 2 days each) [10]
and 60 mg of prednisone for 7 days then tapering to 10 mg
every other day to stop at day 17 [9]. All of the studies
­evaluated total surgical blood loss with only 1 observing a Fig. 5.1  Reverse Trendelenberg position
statistically significant difference in blood loss between the
steroid vs. the placebo groups [9]. 3 of the 4 studies assessed decrease in surgical time [12–14] at angles of 10–20°.
surgical field quality using either a visual analog scale or the Cerebral perfusion and cerebral blood flow appear preserved
Boezaart score. Studies by Sieskiewicz et al. and Ecevit et al. provided that the angle head elevation does not exceed 30°.
found an improvement of surgical field quality in the pre-­ The authors recommend using a clinometer (available on
operative systemic steroid groups [8, 9]. Results from both of most handheld mobile devices) to accurately determine the
these studies also showed a reduction in operative time favor- angle of head tilt while the patient is positioned to ensure that
ing the steroid group. A meta-analysis by Hwang et al. exam- the angle is not under or overestimated.
ined 5 studies and concluded that intra-operative bleeding
and operative time during endoscopic sinus surgery were
significantly reduced in the pre-operative steroid group along 5.4 Local Anesthesia
with improved surgical field visibility [11]. Given the above
evidence, both the EPOS 2020 guidelines and the 5.4.1 Injected
RS-ICAR-2021 document recommend the use of oral corti-
costeroids prior to endoscopic sinus surgery [2, 6]. Although Local anesthetic agents containing epinephrine are often
no evidence-based agreement on dosage or duration has been used in sinus surgery to improve hemostasis via local vaso-
agreed upon; the RS-ICAR-2021 document suggests that a constriction; however, epinephrine can have complex cardio-
commonly prescribed regimen is 30–60 mg within 7 days of vascular adverse effects. Hypertension and tachycardia are
surgery with or without tapering is safe and effective [6]. well established consequences of high doses of epinephrine,
while low doses of epinephrine combined with local anes-
thetic agents can lead to vasodilation causing hypotension
5.3 Patient Positioning [15]. Lee et al. found that local infiltration with epinephrine
was associated with a sharp spike in mean arterial blood
By adjusting the angle of the operating table, surgeons have pressure [16].
been able to alter the vascular supply to the operative field. The value of infiltration of local anesthetic agents con-
Locally, the reverse Trendelenburg position (RTP) has been taining epinephrine is often a subject of debate. Although a
shown to reduce mucosal blood flow and venous pressure in randomized control trial by Cohen-Kerem et al. showed ben-
the surgical field by diverting blood to the extremities efit in the operative field with local anesthetic/epinephrine
(Fig. 5.1). Systemically, this position reduces venous return infiltration compared to saline, this result was not reproduc-
and cardiac output leading which results in a decreased mean ible in a similarly designed study by Javer et al. [17, 18]. In
arterial blood pressure. Three randomized control trials have addition, the study by Lee et al. did not find any benefit of
been performed assessing the effect of the RTP on ESS. They local infiltration of epinephrine in terms of duration of sur-
found that a position of 10–20° RT compared to horizontal gery and total blood loss [16]. A meta-analysis examining
position (0–5°) resulted in a significantly improved surgical epinephrine use in sinus surgery for hemostasis demon-
field measured with the Boezaart scale, with Gan et al. also strated that topical and injectable epinephrine are equally
showing a reduction in blood flow at the head of the inferior effective and more beneficial than placebo [19]. In terms of
turbinate by 38% with a 20° tilt. All three studies also dosage, two studies have concluded that the 1:200,000 dos-
reported a significant reduction of total blood loss and a age is most beneficial with lower risk of cardiovascular com-
5  Pre-operative Medical Management 61

plications [20, 21]. An alternative to local injection at the

surgical site is infiltration of the pterygopalatine fossa (PPF)
via the greater palatine canal. This technique has been shown
to improve the surgical field in endoscopic sinus surgery [22]
possibly by vasoconstrictive action of the epinephrine or by
local compression of the internal maxillary artery by increas-
ing the volume in the PPF as shown in older studies where
plain xylocaine, water, or glycerine were injected [23, 24].

5.5 Topical Agents

Topical sinonasal vasoconstrictor application immediately

prior to and during sinus surgery is another strategy to
improve the surgical field intra-operatively. The various
aqueous and paste-based formulations include cocaine, epi- Fig. 5.2  Pre-operative setup for application of topical vasoconstric-
nephrine, phenylephrine, and oxymetazoline [25]. Cocaine tion/anesthetic and injectable local anesthetic for septum and sinus
is an excellent vasoconstrictor and anesthetic but carries a surgery
risk of cardiac toxicity. Historically, cocaine used to be the
topical agent of choice; however, it has fallen out of favor temic blood pressure via non-selective vasodilation of cerebral
over the years, as other agents such as topical epinephrine and peripheral blood vessels. This can result in reflex tachy-
(11000) have been found to achieve similar benefits without cardia which reduces end-diastolic filing time and thereby
the cardiotoxic potential [26]. Dosing studies suggest that increases venous pooling in the surgical field. Total intrave-
epinephrine concentrations of 1:1000–1:2000 can be safely nous anesthesia (TIVA) is usually achieved with a continuous
used in adults age 18 or greater but should be avoided in infusion of propofol and an opioid, such as remifentanil, and
patients weighing less than 45 pounds or in the setting of pre-­ has been shown to improve surgical field bleeding [33]. Unlike
existing cardiovascular disease [25, 27–29]. In the pediatric their inhalational counterparts, intravenous agents such as pro-
population, oxymetazoline alone has been shown to be as pofol cause vasodilation through central sympathetic tone
effective as phenylephrine or cocaine in terms of vasocon- suppression resulting in no effect on the peripheral vasculature
striction which improved bleeding and visualization [30]. with maintenance of baseline catecholamines and pre-arterio-
Although it is common practice, surgeons to use both topical lar capillary sphincter tone [33]. In addition to MABP, heart
oxymetazoline in conjunction with epinephrine is not recom- rate control of 60 bpm has been shown to significantly improve
mended, as the occupation of the alpha adrenergic receptors the surgical field and mucosal bleeding by increasing venous
with a partial agonist (oxymetazoline) reduces the efficacy of return away from the surgical field through prolongation of
epinephrine, a complete alpha receptor agonist, and further- end-diastolic filling time [34, 35].
more makes its action less predictable. Since topical phenyl- Multiple studies have compared TIVA versus inhala-
ephrine has been implicated in several pediatric and adult tional anesthesia and their effects on surgical view and
deaths, this medication should not be used in endoscopic blood loss in sinus surgery [31]. One systematic review and
sinus surgery [25]. Figure 5.2 illustrates a pre-operative meta-­analysis found that TIVA may provide another better
setup for the application of topical vasoconstriction/anes- surgical field, while a systematic review could not make a
thetic and injectable local anesthetic for septum and sinus conclusion due to study heterogeneity and limitations [36,
surgery. 37]. Two Cochrane reviews demonstrated no significant dif-
ference in blood loss but showed that TIVA may provide a
slight improvement in surgical visualization compared to
5.6 Anesthetic Agents inhalation anesthesia [38, 39].
Clonidine and dexmedetomidine are alpha-2-adrenergic
Sinonasal mucosal bleeding is a function of the mean arterial agonists that produce hypotension via inhibition of norepi-
blood pressure (MABP) and central venous pressure [31]. nephrine release in the central nervous system and simulta-
Controlled hypotension with a MABP of 60–70 mmHg is con- neously constrict the peripheral vasculature [31]. Studies
sidered the ideal in healthy individuals to reduce mucosal comparing TIVA techniques based on clonidine and dexme-
bleeding [32]. Both volatile agents and intravenous agents can detomidine versus remifentanil-based TIVA demonstrated
achieve controlled hypotension; however, their mechanisms of that clonidine improved surgical field scores while dexme-
action differ. Inhalation agents mediate their reduction in sys- detomidine is similar to remifentanil in surgical field condi-
62 Y. Chan and A. J. Psatis

tion control [40–43]. Controlled hypotension plays an clonidine, dexmedetomidine, or remifentanil may also
important role in optimizing surgical field visualization with improve the quality of the surgical field during sinus surgery.
a safe MABP target of between 60 and 70  mmHg, with The employment of one or more of these strategies is depen-
maintenance of adequate cerebral perfusion above this level. dent on patient factors and surgical team comfort, prefer-
Once the MABP is reduced to below 60 mmHg, there is a ence, and experience.
precipitous drop in intracerebral perfusion to less than 90%,
with the elderly particularly at risk of short-term cognitive
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 Classification of the Frontal Sinus
Anatomy, the Extent, and Complexity 6
of the Frontal Sinus Endoscopic Surgery

Claudio Callejas and Claudia González

6.1 Introduction 6.2 International Frontal Sinus Anatomy

Classification (IFAC) [1]
A perfect understanding of the anatomy when performing
frontal sinus surgery is key to achieving a successful surgery Successful, safe, and efficient frontal sinus surgery relies
safely and efficiently. This anatomy is highly variable heavily on adequate surgical training and mastering the
between patients and has a wide range of complexity. region’s anatomy. Like fingerprints, frontal sinus anatomy
Although frontal sinus surgery is technically challenging varies significantly between patients, mainly because of vari-
and, in general, not considered easy, depending on the anat- ations in the pneumatization of ethmoid cells into the frontal
omy, the complexity of cases can range from less difficult to recess and frontal sinus. Fortunately, patterns on how this
really complex cases that require a high level of training and pneumatization may occur have been identified, which have
expertise. Although many variables can influence the degree allowed us to systematize the understanding of this region’s
of difficulty of a case (e.g., degree of mucosal inflammation anatomy.
or history of previous surgery, among others), from the point Usually, an adult patient has two frontal sinuses, although,
of view of the anatomy, complexity is mainly dependent on in the normal population, it can be aplastic in one (5%) or
the number and distribution of cells in the frontal recess and both sides (8%) [3, 4]. The sinus is located within the frontal
frontal sinus, and the size of the frontal ostium. bone and is limited by the anterior and posterior tables. The
Creating a mental 3D image of the frontal sinus and fron- transition from the frontal sinus to the frontal recess has an
tal recess anatomy and the spatial distribution of the cells hourglass shape. Unlike the ostia of other sinuses (e.g., max-
around the frontal ostium is a skill that requires practice and illary or sphenoid sinus), the frontal sinus ostium is not a real
time to develop. Similar to learning a new language, at first, anatomic structure but rather a conceptual definition. The
it is a time-consuming process. It turns into an automatic frontal ostium is defined as the narrowest area of the transi-
process with persistent practice, just like the student starts to tion zone from the frontal sinus to the frontal recess, with its
think in a foreign language after enough exercise. anterior limit formed by the frontal sinus beak, hence it usu-
A group of leading rhinologists worldwide proposed three ally has an oblique direction rather than a horizontal [1]
classification systems to clarify and simplify concepts (Fig. 6.1). The frontal sinus drains through the frontal ostium
regarding frontal sinus surgical anatomy. They are: (1) The in a space known as the frontal recess. The frontal recess is
International Frontal Sinus Anatomy Classification (IFAC) an inverted, cone-shaped space with the superior narrow end
[1], (2) The Classification of the Extent of Endoscopic at the frontal ostium. It is limited anteriorly by the frontal
Frontal Sinus Surgery (EFSS) [1], and (3) The International beak (the nasal process of the frontal bone); posteriorly by
Classification of the Radiological Complexity (ICC) of fron- the skull base and basal lamella of the middle turbinate; lat-
tal recess and frontal sinus [2]. This chapter will present and erally by the lamina papyracea; and medially by the vertical
discuss these classifications. They will help the surgeon in lamella of the middle turbinate and the lateral wall of the
the decision-making process and in the planning of frontal olfactory fossa (lamella lateral) [1]. Frequently, frontal cells
sinus surgery to improve surgical outcomes. are located only in the frontal recess, or they extend superi-
orly to encroach the frontal ostium, but less frequently, they
extend into the frontal sinus itself through the frontal ostium.
Therefore, frontal sinus surgery often takes place mainly in
C. Callejas (*) · C. González the frontal recess.
Department of Otolaryngology, Pontificia Universidad Católica de
Chile, Santiago, Chile

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 65

D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_6
66 C. Callejas and C. González

surgery must rely on these last elements and not on naviga-

tion systems. They help to check anatomy in complex situa-
tions, but surgical dissection should not be driven by
navigation, but by anatomical knowledge.
As previously stated, a three-dimensional understanding
of the frontal recess anatomy begins with an accurate CT
scan analysis in the three planes. A fine-cut protocol of image
acquisition must be ordered before surgery. These images
must be loaded in a DICOM image viewer software for
three-plane reconstruction and analyzed using a bone win-
dow protocol. Slices should be less than 1 mm thick. Thicker
slices will give inaccurate pixelated images. Various Apple
or Microsoft compatible software are available for free or
licensed use [18–21]. We strongly encourage the reader to
familiarize themselves with one of them and routinely have
it available during the surgery to review the anatomy, espe-
cially if navigation is not used.
According to IFAC classification, frontal cells are grouped
initially, considering the anatomic structure to which they
Fig. 6.1  Parasagittal CT scan. Redline: frontal sinus ostium; Blue line: are attached into anterior, posterior, or medial cells, Table 6.1.
frontal sinus beak; Pink shaded area: frontal process of the maxilla; There is a wide range of combinations of how these cells can
Green line: basal lamella of the middle turbinate; Yellow shaded area:
frontal recess be present in different patients, from some only having an
agger nasi cell to others having all of them at once [22–24].
Most patients will have different combinations of only some
Various classifications of the frontal sinus anatomy have of them. It is key to identify them and build a mental image
been proposed since the beginning of endoscopic sinus sur- of how they relate to each other and to the frontal sinus drain-
gery [5–8]. Built on the work of van Alyea [9], Kuhn [5, 7, age pathway. In this chapter, they will be illustrated using
10, 11], and Wormald [12–17], the authors of IFAC d­ eveloped images from two patients. Patient 1 had surgery to treat
a consensus classification that will allow the surgeon to make localized primary frontal CRS, and patient 2 to treat diffuse
a mental picture of the relationship between the different CRS (Fig. 6.2).
types of cells within the frontal recess and frontal sinus, and
how they push the frontal sinus drainage pathway. An essen-
tial feature of this classification is that it avoids eponyms, 6.2.1 Anterior Cells
and instead, cells are named according to their relation to
very well-known and constant cells, namely the agger nasi Anterior cells most probably originate from variations in the
cell and the bulla ethmoidalis. Hence, it is easy to remember insertion of the uncinate process (first basal lamella) [22].
and implement. On the parasagittal plane of the CT scan, these cells can be
A comprehensive analysis of the preoperative CT scans is recognized as their anterior wall is attached to the frontal
fundamental to creating a three-dimensional mental repre- process of the maxilla. If the cell extends high enough, it will
sentation of this area. Reconstruction in the three planes also be attached to the frontal beak or the anterior table of the
(axial, coronal, and sagittal) is mandatory to figure out from frontal bone. These cells displace the frontal sinus drainage
the CT scans the cells’ spatial distribution. This analysis will pathway posteriorly or, usually, posteromedially. They can
allow the surgeon to create a surgical plan so that dissecting also push it medially (Fig. 6.3).
instruments can be precisely placed with minimal risk and
achieve complete clearance of the cells within this area. 6.2.1.1 Agger Nasi Cell (ANC)
Navigation systems have become a helpful tool giving feed- Usually it is the more anterior ethmoid cell. Located either
back in this regard. However, they do not replace adequate anterior to the middle turbinate’s origin or sits directly above
surgical training and the knowledge of anatomy the surgeon the middle turbinate’s most anterior insertion into the lateral
must master. This chapter’s authors believe that frontal sinus nasal wall (Fig. 6.4).
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 67

Table 6.1  International frontal sinus anatomy classification (IFAC) [1]

Cell type Cell name Definition Abbreviation
Anterior cells (push the drainage Agger nasi cell A cell that sits either anterior to the origin of the middle turbinate ANC
pathway of the frontal sinus medial, or sits directly above the most anterior insertion of the middle
posterior, or posteromedially) turbinate into the lateral nasal wall
Supra-agger cell Anterior-lateral ethmoidal cell, located above the agger nasi cell SAC
(not pneumatizing into the frontal sinus)
Supra-agger Anterior-lateral ethmoidal cell that extends into the frontal sinus. A SAFC
frontal cell small SAFC will only extend into the frontal sinus floor, whereas a
large SAFC may extend significantly into the frontal sinus and may
even reach the roof of the frontal sinus
Posterior cells (push the drainage Supra-bulla cell Cell above the bulla ethmoidalis that does not enter the frontal sinus SBC
pathway anteriorly)
Supra-bulla Cell that originates in the supra-bulla region and pneumatizes along SBFC
frontal cell the skull base into the posterior region of the frontal sinus. The
skull base forms the posterior wall of the cell
Supraorbital An anterior ethmoid cell that pneumatizes around, anterior to, or SOEC
ethmoid cell posterior to the anterior ethmoidal artery over the roof of the orbit.
It often forms part of the posterior wall of an extensively
pneumatized frontal sinus and may only be separated from the
frontal sinus by a bony septation
Medial cells (push the drainage Frontal septal cell Medially based cell of the anterior ethmoid or the inferior frontal FSC
pathway laterally) sinus, attached to or located in the interfrontal sinus septum,
associated with the medial aspect of the frontal sinus outflow tract,
pushing the drainage pathway laterally and frequently posteriorly

Fig. 6.2  Patient 1: Coronal (a) and parasagittal (b) CT scans showing frontal septal cell (FSC). Patient 2: Coronal (c) and Axial (d) CT scans
agger nasi cell (ANC), supra-agger cell (SAC), supra-agger frontal cell showing supraorbital ethmoid cell (SOEC). Asterisks: frontal sinus
(SAFC), supra-bulla cell (SBC), supra-bulla frontal cell (SBFC), and
68 C. Callejas and C. González

6.2.1.2 Supra-Agger Cell (SAC)

It corresponds to an anterior-lateral ethmoidal cell located
above the agger nasi cell but is not pneumatized into the
frontal sinus. It can be one cell or a group of cells (Fig. 6.5).

6.2.1.3 Supra-Agger Frontal Cell (SAFC)

It is an anterior-lateral ethmoidal cell that extends in various
degrees into the frontal sinus. In some patients, this cell may
even reach the roof of the frontal sinus. In the coronal CT
scan, they are typically seen as “sitting” on the frontal beak
(Fig. 6.6).

6.2.2 Posterior Cells

The different posterior cells most likely originate from varia-

tions in the insertion of the front face of the bulla ethmoidalis
Fig. 6.3  Parasagittal CT scan modified to show drawings of the anteri-
orly based cells of the frontal recess. Orange: agger nasi cell (ANC); (second basal lamella). In the parasagittal plane of the CT
blue: supra-agger cell (SAC); green: supra-agger frontal cell (SAFC). scan, these cells are easily recognized by their posterior
Observe how these cells push the frontal sinus drainage pathway poste- attachment to the skull base, above the bulla ethmoidalis,
riorly (usually posteromedially). They can also push it medially

Fig. 6.4  Patient 1: Three-plane reconstruction. (a) Parasagittal, (b) maxilla. It pushes the frontal sinus drainage pathway (pink dot) pos-
Coronal, (c) Axial CT scans. Crosshairs show the agger nasi cell teromedially. (d) Endoscopic view of the opened agger nasi cell with a
(ANC). Observe its anterior attachment to the frontal process of the 0° scope (asterisk)
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 69

Fig. 6.5  Patient 1: Three-plane reconstruction. (a) Parasagittal, (b) flap technique [23], which allows the surgeon to look and work in the
Coronal, (c) Axial CT scans. Crosshairs are showing a supra-agger cell frontal recess at a more straight angle, deferring the use of angle scopes
(SAC), located above the small agger nasi cell. (d) Endoscopic view of and instruments for a more advanced stage in the dissection to resect
the opened supra-agger cell with a 0° scope (asterisk). It was possible to cells encroaching into the frontal ostium
have a frontal view of this cell with the 0° scope, thanks to the axillary

anterior to the insertion of the basal lamella of the middle 6.2.2.2 Supra-Bulla Frontal Cell (SBFC)
turbinate. These types of cells push the frontal sinus drainage The cell originates in the supra-bulla region and pneumatizes
pathway anteriorly (Fig. 6.7). along the skull base into the posterior region of the frontal
sinus. The skull base forms the posterior wall of the cell,
6.2.2.1 Supra-Bulla Cell (SBC) Fig. 6.9.
Cell or group of cells above the bulla ethmoidalis that do not Large SAFC and SBFC can be easily confused with the
enter into the frontal sinus, Fig. 6.8. frontal sinus (Fig.  6.10). It is essential to have this in mind
70 C. Callejas and C. González

Fig. 6.6  Patient 1: Three-plane reconstruction. (a) Parasagittal, (b) opened SAFC with a 0° scope (asterisk in A corresponds to the area
Coronal, (c) Axial CT scans. Crosshairs are showing a supra-agger marked with an asterisk in (d). The white arrow shows the inferior wall
frontal cell (SAFC). Image (a) has been modified to illustrate the pro- of the SAFC. Note how, in both frontal sinuses, there is an SAFC “sit-
gression of the surgery shown in (d) (cells surgically removed have ting” on the frontal beak, highlighted on the right side of the patient (b:
been erased from the CT scans images). (d) Endoscopic view of the pink shaded area: right frontal beak)

Fig. 6.7  Parasagittal CT scans modified to show drawings of the posteri- cell (SBC); (b) yellow: supra-bulla frontal cell (SBFC). Observe its exten-
orly based cells of the frontal recess. (a) The dotted line shows the location sion into the frontal sinus through the ostium and the location of the frontal
of the frontal ostium. Purple: bulla ethmoidalis (BE); light blue: supra-bulla sinus drainage pathway (purple arrow) anterior to the posterior cells
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 71

Fig. 6.8  Patient 1: Three-plane reconstruction. (a) Parasagittal, (b) noidotomy were carried out. After identifying the skull base at the sphe-
Coronal, (c) Axial CT scans. Crosshairs show a supra-bulla cell (SBC). noid sinus, cells were cleared from the skull base from back to front. In
Image (a) has been modified to illustrate the progression of the surgery (a), the SBC has not been opened yet. (d) Endoscopic view (45-degree
before opening the SBC (cells surgically removed have been erased scope) of the SBC opened (asterisk). Note the septum inside the cell
from the CT scans images). After removing anteriorly based cells, the that can be seen in the coronal CT scan (white arrow)
bulla complex was resected, and a posterior ethmoidectomy and sphe-

when operating on patients with large cells protruding into the artery over the roof of the orbit. Its main characteristic is that
frontal sinus. Useful anatomical landmarks to corroborate it is mainly pneumatized above the orbit (laterally), and
proper exposure of the frontal sinus are anteroposterior septa- therefore, when present, the anterior ethmoidal artery is
tions that can be seen in the roof of the frontal sinus and being located in a mesentery in the anterior ethmoid. It can pneu-
able to see the curvature of the posterior table (Fig. 6.13). matize anteriorly in a variable degree, even encroaching on
the frontal sinus ostium. When looking at the parasagittal CT
6.2.2.3 Supraorbital Ethmoid Cell (SOEC) scans, it looks like an SBC or small SBFC (depending on if
Corresponds to a posterior ethmoid cell that pneumatized it enters the frontal sinus or not). Hence, coronal scans are
around, anterior to or posterior to the anterior ethmoidal best to identify its extension above the orbit (Fig. 6.11).
72 C. Callejas and C. González

Fig. 6.9  Patient 1: Three-plane reconstruction. (a) Parasagittal, (b) to illustrate the progression of the surgery before opening the SBFC
Coronal, (c) Axial CT scans. Crosshairs mark the supra-bulla frontal (cells surgically removed have been erased from the CT scans images).
(SBFC). Observe how it is pneumatized through the frontal sinus (d) Endoscopic view (45-degree scope) of the following opened cells:
ostium in (a). Also, note the red dot representing the anterior ethmoid SBFC (asterisk), SBC (black circle), and SAFC (triangle). The white
artery (AEA) located in its posterior wall. Image (a) has been modified arrow shows the lateral aspect of the AEA
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 73

Fig. 6.10  Patient 1: Three-plane reconstruction. (a) Parasagittal, (b) removing its inferior wall. (d) Endoscopic view of the widely opened
Coronal, (c) Axial CT scans. Crosshairs are showing a supra-bulla fron- supra-agger frontal cell (SAFC) with a 45-degree scope (white aster-
tal cell (SBFC). Image A has been modified to illustrate the progression isk). Note how it can resemble a frontal sinus if the surgeon is not aware
of the surgery shown in (d) (cells surgically removed have been erased of the size of the SAFC. The suction curette is approaching the poste-
from the CT scans images). The ANC, SAC, bulla ethmoidalis, and rior wall of the SAFC (black arrow) to find the frontal sinus drainage
posteriorly based cells of the frontal recess have been surgically pathway that has been squeezed against the anterior wall of the supra-­
removed, and the SAFC (white asterisk) has been widely opened, bulla frontal cell (white dot: SBFC roof)
74 C. Callejas and C. González

Fig. 6.11  Patient 2: Radiological example of a left supraorbital eth- tal sinus. On the parasagittal CT, the SOEC looks similar to an SBFC
moid cell (SOEC). Three-plane reconstruction. (a) Parasagittal CT with entering into the frontal sinus; however, on the coronal and axial CT
a diagram. The red cell corresponds to the SOEC encroaching the fron- scans, the cell is seen to be pneumatized over the orbit, making this an
tal ostium. The red dot in its posterior wall represents the anterior eth- SOEC rather than an SBFC. The white arrow shows the origin of the
moid artery (AEA). The purple cell represents the bulla ethmoidalis AEA in the coronal CT scan
(BE). (b) Coronal. (c) Parasagittal. (d) Axial CT scans. Asterisks: fron-
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 75

Fig. 6.12  Patient 1: Three-plane reconstruction. (a) Parasagittal, (b) (asterisk). Note that all the cells in the frontal recess and within the
Coronal, (c) Axial CT scans. Crosshairs mark the frontal septal cell frontal sinus, including the SFAC and SBFC, have been removed, and
(FSC). (d) Endoscopic view (45-degree scope) of the FSC opened the roof of the frontal sinus can be seen (white circle)

6.2.3 Medial Cells 6.2.3.1 Frontal Septal Cell (FSC)

It is attached to or in close relation to the interfrontal sinus sep-
There is only one type of medially based cell. Its main fea- tum, associated with the medial aspect of the frontal sinus out-
ture is that it pushes the frontal sinus drainage pathway flow. This cell displaces the frontal sinus pathway ­laterally and
laterally. frequently posteriorly (Fig. 6.12). Characteristically it has thick
76 C. Callejas and C. González

Fig. 6.13  Patient 1: Endoscopic view (45-degree scope) of the frontal frontal sinus. The FSC has been marsupialized into the frontal sinus
recess and frontal sinus after complete healing of the mucosa. (a) White (asterisk). (b) Black dot: Roof of SBFC, black arrow: AEA, white dot:
arrow: anteroposterior septation in the roof of the frontal sinus. Note roof of SBC (c) in photograph c, the white dot is located in the septum
also how the curvature of the posterior table can be seen within the inside the SBC

bony walls, which are not easy to remove with curettes. Punch Table 6.2  Frontal sinus procedures: equivalence between EFSS and
instruments are usually required to remove them (Fig. 6.13). Draf classification
Classification of the Extent of Endoscopic Frontal sinus procedures.
Frontal Sinus Surgery (EFSS) Draf classification [6]
Grade 0 Not considered in Draf
6.3 Classification of the Extent classification
of Endoscopic Frontal Sinus Surgery Grade 1 Draf IIA
(EFSS) [1] Grade 2 Draf IIA
Grade 3 Draf IIA
The same group of rhinologists that developed the IFAC pro- Grade 4 Not considered in Draf
posed this classification with the intention of categorizing dif- classification
ferent frontal sinus endoscopic procedures in a balanced and Grade 5 Draf IIB
Grade 6 Draf III—Modified
progressive manner according to the extent of surgery involved.
endoscopic Lothrop
As expected, it also turned out to be a good reflection of the procedure
degree of surgery difficulty. The higher the grade (more exten-
sive surgery), the higher the surgical complexity of the case.
Procedures were grouped into three categories according process of the maxilla and frontal beak) leading to enlarge-
to how much tissue removal was involved: (1) procedures ment of the frontal sinus ostium.
without tissue removal, (2) procedures in which only cells Table 6.2 resumes the equivalence of frontal sinus proce-
are removed (no change in frontal ostium size is performed), dures between EFSS and Draf Classification.
and (3) procedures involving bone removal (mostly frontal Frontal sinus procedures have been defined as follows:
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 77

6.3.1 No Tissue Removal Grade 2: Clearance of cells directly obstructing the fron-
tal sinus ostium (this grade excludes patients having SAFCs,
Grade 0: Balloon sinus dilatation (see Chap. 9). SBFCs, or FSCs). These cells are SACs or SBCs that encroach
on and obstruct the frontal sinus drainage (Fig. 6.14b, e).
Grade 3: Clearance of cell pneumatization through the
6.3.2 Frontal Recess Clearance Procedures frontal ostium into the frontal sinus, without enlargement of
the frontal ostium. These cells are typically SAFC, SBFC, or
They are classified according to how high in the frontal FSC, Fig. 6.14c, f.
recess or frontal sinus the surgeon needs to work to remove This classification assumes the philosophy of all or nothing
the frontal cells. The higher the surgeon needs to work, the regarding frontal sinus surgery. That is, when performing frontal
more angled scopes and handheld instruments are required, sinus surgery, all of the frontal cells need to be removed. No
making the surgery more difficult. cells are left behind. Hence, performing a grade 1, 2, or 3 proce-
Grade 1: Clearance of the cells in the frontal recess with- dure depends on the anatomy of the patient and should not be an
out any surgery within the frontal ostium. These cells are arbitrary decision of the surgeon. For example, it does not make
SACs and SBCs that do not directly obstruct the frontal sinus sense to perform a grade 1 procedure in a patient with cells
ostium, Fig. 6.14a, d. extending into the frontal sinus (e.g., SAFC or SBFC).

Fig. 6.14  Frontal recess clearance procedures. Parasagittal CT scans. (a–c) show the distribution of cells in the frontal recess. (d–f) are drawings
on the CT scan showing how always all the frontal cells need to be removed
78 C. Callejas and C. González

6.3.3 Frontal Ostium Enlargement Grade 5: Enlargement of the frontal ostium from the
Procedures by Removal of Bone lamina papyracea to the nasal septum, removing the
from the Frontal Beak whole frontal sinus floor unilaterally. It corresponds to a
Draf IIb procedure according to the Draf classification
Bone removal procedures are the most technically demand- (Fig. 6.16).
ing procedures that require a high level of training, mainly Grade 6: Removal of the entire floor of both frontal
grades 5 and 6, which are usually performed employing sinuses from the lamina papyracea of one side to the other,
drilling. connecting their ostia to form a common aperture with a
Grade 4: Clearance of cell pneumatization through the septal window. Posteriorly, the first olfactory neuron has to
frontal ostium into the frontal sinus, with enlargement of the be identified on each side to detect the anterior projection
frontal ostium by removing some bone from the frontal sinus of the cranial fossa. Anteriorly, the dissection has to be
beak. These are typically large SAFCs, large SBFCs, or extended until exposing a small area of periosteum under
FSCs with a narrow AP diameter of the frontal ostium. As the skin. This will confirm obtaining the maximum possi-
only part of the beak is removed and drilling heals with sig- ble aperture. Grade 6 procedure corresponds to the Draf III
nificant stenosis, using punches when possible is preferable or Endoscopic Modified Lothrop Procedure (Figs.  6.17
(Fig. 6.15). and 6.18).

Fig. 6.15 (a) Parasagittal CT scan showing a very narrow frontal ostium. (b) The image has been modified to illustrate a grade 4 procedure. Note
how a segment of the most prominent part of the frontal beak has been removed along with the superior insertion of the supra-agger cell
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 79

Fig. 6.16 (a) Mucocele of the right frontal sinus. (b) Diagram repre- first olfactory neuron was identified in order to determine the anterior
senting the bone removed with a grade 5 procedure. (c) Endoscopic extent of the cranial fossa. The horizontal white line represents the ante-
view (0-degree scope) at the end of drilling a grade 5 procedure in the rior extension of the cranial fossa. (d) Postoperative endoscopy. Note
right frontal sinus. The nasal septum was left intact (asterisk), and the that although the right frontal sinus is widely patent, there is significant
entire right frontal sinus floor was removed between the septum medi- scarring and stenosis. Given the significant postoperative stenosis
ally and the lamina papyracea laterally. Anteriorly, the dissection was expected when drilling in this area, consider making the widest possible
extended until exposing a small area of periosteum under the skin. The opening by removing the whole floor of the frontal sinus
80 C. Callejas and C. González

Fig. 6.17 (a) Coronal CT scan showing complete opacification of the 6 procedure. (d) Grade 6 procedure, endoscopic view at the end of the
right frontal sinus caused by an inverted papilloma. (b) Coronal MRI surgery. The white line indicates the anterior projection of the skull
T2 weighted image showing the location of the inverted papilloma in base
the frontal sinus. (c) Diagram represents the bone removed with a grade
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 81

Fig. 6.18  Follow-up endoscopic view using a 30-degree scope of a the skull base runs continuously from the fovea ethmoidalis up to the
grade 6 procedure. (a) Observe the wide opening communicating both posterior table of the frontal sinus. Arrow: Anterior ethmoidal artery.
frontal sinuses with the nose. On the left side, it can be observed how (b) Closer view of the frontal sinuses

Table 6.3  International Classification of Complexity (ICC) [2]

6.4 The International Classification Wide APa Narrow APa Very narrow
of the Radiological Complexity (ICC) diameter diameter AP diameter
of Frontal Recess and Frontal Sinus [17] (≥10 mm) (9–6 mm) (≤5 mm)
Cells below the Less Moderate High
The frontal sinus is considered the most challenging sinus ostium (ANC, complex complexity complexity
SAC, SBC) (grade 1) (grade 2) (grade 3)
to operate on, and frontal sinus surgery is, as a general rule,
Cells encroaching Moderate High Highest
never considered easy. Still, frontal sinus surgery has a into the ostium complexity complexity complexity
wide range of complexities, from less complicated cases to (SAFC, SBFC, (grade 2) (grade 3) (grade 4)
very complex ones that require a high level of training and SOEC, FSC)
experience. Cells extending High Highest Highest
significantly into complexity complexity complexity
Regardless of the level of training and experience a sur- the frontal sinus (grade 3) (grade 4) (grade 4)
geon has, it is crucial to determine in advance the degree (SAFC, SBFC,
of difficulty of cases to prepare accordingly for surgery. SOEC, FSC)
Also, when not comfortable with the full range of com- a
AP refers to the frontal ostium anterior-posterior diameter as measured
plexities of frontal sinus surgery, being able to determine from the frontal beak to the skull base on the parasagittal CT scan. AP
anterior-posterior, CT computed tomography, FSC frontal septal cell,
that, will allow the surgeon to select cases according to his
IFAC International Frontal Sinus Classification, SAC supra-agger cell,
or her level of training and refer the more complex cases. SAFC supra-agger frontal cell, SBC supra-bulla cell, SBFC supra-bulla
This will permit the surgeon to achieve the best possible frontal cell, SOEC supraorbital ethmoid cell
outcomes.
Several factors influence the degree of difficulty of a case.
There are patient-dependent factors, mainly anatomical fea- frontal sinus surgery based solely on the preoperative CT
tures, disease-dependent factors (e.g., degree of mucosal scans in primary cases. It considers only two variables: the
inflammation or distortion of the anatomy as in allergic fun- degree of pneumatization of ethmoid cells into the frontal
gal sinusitis), and history of previous surgery, leading to sinus and the anteroposterior (AP) length of the frontal
alteration of anatomical landmarks, scarring tissue, and ostium. Each variable was divided by consensus into three
osteoneogenesis. possible options, creating a three-by-three table that classi-
The International Classification of the Radiological fies frontal sinus surgery within four possible levels of diffi-
Complexity (ICC) of frontal recess and frontal sinus was culty: less complex, moderate complexity, high complexity,
developed to predict the degree of surgical complexity of and highest complexity (Table 6.3; Fig. 6.19).
82 C. Callejas and C. González

Fig. 6.19  Parasagittal CT scans showing different levels of complexi- diameter of the frontal sinus ostium and an SBC encroaching into the
ties according to The International Classification of the Radiological frontal sinus ostium. Asterix: contralateral frontal sinus. The surgeon
Complexity of frontal recess and frontal sinus. (a) Less complex: wide must be very skilled to properly clear the ostium area by gently resect-
AP diameter of the frontal sinus ostium and cells below the ostium ing the insertion of the SBFC in the skull base in a very narrow space.
(ANC and bulla ethmoidalis). (b) High complexity: wide AP diameter Maximum attention to preserving intact mucosa at the level of this nar-
of the frontal sinus ostium and cells extend significantly into the frontal row ostium is required to avoid scarring and subsequent obstruction of
sinus (SAFC and SBFC). (c) Highest complexity: very narrow AP the frontal sinus drainage

The degree of pneumatization of the ethmoids cells into Another advantage of this classification system is that it
the frontal sinus is best assessed by looking at the parasagit- allows standardized and hence comparable reporting. This is
tal CT scans. It was divided into three according to their useful in research as it allows evaluation of outcomes in fron-
highest extension towards the frontal sinus: Cells only below tal sinus surgery, considering the degree of difficulty of the
the frontal ostium, cells encroaching into the ostium, or cells cases studied. Besides, having a classification system to
extending significantly into the frontal sinus. assess the degree of frontal sinus surgery complexity is very
The AP diameter of the frontal ostium should be deter- useful for the training of surgeons. It allows users to select
mined using parasagittal CT scans. The frontal ostium was cases according to their level of experience and progress
defined as the shorter distance from the posterior aspect of safely and comfortably through wide range of complexities.
the most prominent part of the frontal beak to the skull base This will help learn frontal sinus surgery as challenging and
(hence it has an oblique direction rather than horizontal). To enjoyable, decreasing the chances of complications and fail-
be representative, the AP diameter of the frontal ostium has ures, rather than an unpleasant and traumatic experience.
to be measured in the parasagittal scan, where this distance is As previously stated, the classification of the extent of endo-
the largest. A wide AP diameter was by consensus defined as scopic frontal sinus surgery does correlate with the degree of
an AP distance ≥10 mm, a narrow AP diameter was defined surgical complexity. The International Classification of the
as an AP distance of 6 to 9 mm, and a very narrow AP dis- Radiological Complexity of frontal recess and frontal sinus adds
tance was defined as a measurement of ≤5 mm. It was shown to this. For example, when considering the difficulty of a grade 3
that this distance could be accurately visually estimated by procedure, performing it in a patient with a narrow frontal ostium
the experienced rhinologist [17]. will be more complicated than in a patient with a wide one.
One of the main advantages of this classification is that it Similarly, performing a grade 6 procedure (Draf III) is more
is deductible based just on two variables. It is easy to remem- challenging when the AP diameter is very narrow compared to a
ber and apply. The downside of this is that it does not con- wide one. Conversely, very complex anatomy may warrant esca-
sider every variable that can influence the degree of difficulty, lation in the extent of surgery to clear all the frontal cells prop-
but when designing the classification system, easiness to erly. For example, to adequately remove a large SAFC or SBFC
remember and apply was favored over a very precise but from inside a frontal sinus with a very narrow AP diameter, a
complex and challenging method. The ICC serves as a handy bone removal procedure may be required. Alternatively, a trephi-
starting point to assess frontal sinus surgery’s difficulty nation can also be considered to remove these cells through a
based on anatomy. combined approach (endoscopic and external).
6  Classification of the Frontal Sinus Anatomy, the Extent, and Complexity of the Frontal Sinus Endoscopic Surgery 83

References 13. Wormald P-J.  Surgery of the frontal recess and frontal sinus.

Rhinology. 2005;43:82–5.
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1. Wormald P-J, Hoseman W, Callejas C, Weber RK, Kennedy DW,
P-J.  Multiplanar reconstructed computed tomography images
Citardi MJ, et al. The international frontal sinus anatomy classifica-
improves depiction and understanding of the anatomy of the frontal
tion (IFAC) and classification of the extent of endoscopic frontal
sinus and recess. Am J Rhinol. 2002;16:119–23.
sinus surgery (EFSS). Int Forum Allergy Rhinol. 2016;6:677–96.
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Wormald P-J.  Endoscopic sinus surgery: anatomy, three-­
2. Wormald PJ, Bassiouni A, Callejas CA, Kennedy DW, Citardi MJ,
dimensional reconstruction and surgical technique. New  York,
Smith TL, et  al. The international classification of the radiologi-
Stuttgart: Thieme Publishers; 2017.
cal complexity (ICC) of frontal recess and frontal sinus. Int Forum
16. Wormald PJ, Chan SZX.  Surgical techniques for the removal of
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 Surgical Planning: Three-Dimensional
Imaging, Stereolithography, and Virtual 7
Surgery

Serafín Sánchez-Gómez, Ramón Moreno-Luna,
Juan Manuel Maza-Solano, Jaime González-García,
and Jesús Ambrosiani Fernández

7.1 Introduction disease including the pattern, location, size, diameter and
volume of the frontal sinuses, frontoethmoidal cells, and
Surgeons need to plan every frontal sinus surgery due to the adjacent bone structures; presence of mucosal thickening,
high inter- and intra-individual anatomical variability of opacification, or tumor; associated bone changes of erosion,
nasosinusal structures, mainly in reinterventions, when it is sclerosis, or sinus expansion; and anatomical landmarks that
common for several structures and anatomical landmarks to determine the spatial configuration of the frontal sinus drain-
be missing [1–4]. Preoperative identification of individual age pathway [35]. Critical anatomical variations and struc-
anatomical variations in every single patient is more relevant tures missed could result in devastating complications or the
than verifying the most common findings published in the persistence of the disease.
literature or found in previous surgeries. Failure of primary Regardless of the name attributed to the structures, the
endoscopic endonasal surgery (EES) to relieve symptoms of key point of surgical planning is to achieve a three-­
frontal sinuses related to CRS occurs in up to 20% of primary dimensional understanding of the frontal sinus drainage
frontal sinus surgeries (see Table 7.1). Although the cause of pathway and frontal recess. The objective is to design a suit-
clinical failure is multifactorial, the presence of remaining able surgical approach to identify and label the target struc-
anatomical elements becomes almost systematically the tures to be removed and the structures to be respected with
indication of reintervention [19–25]. The decision on the frontal ostium exposure [36, 37]. Knowledge of anatomy and
elimination of diseased or anatomically relevant sinonasal presurgical planning is also necessary when establishing
structures for the development or persistence of pathologies indications for external approaches to the frontal sinus, cells
should not be left to chance or to surgeons’ risk aversion that require additional or extended access for removal, or
[26–29], but to careful preoperative planning. Image-guided osteoplastic flaps [38, 39]. Osteoplastic flap is one of the few
surgery (IGS) [30] or intraoperative CT [31, 32] does not situations in which plain film radiographs can still play a role
solve insufficient planning, and these technologies are not in obtaining frontal sinus template, although CT-generated
available in all centers [33, 34]. frontal sinus templates are virtually identical to templates
Planning frontal sinus surgery using image resources, derived from Caldwell’s 6-foot x-ray [40].
such as multiplanar DICOM images, is useful for preoperative
identification of disease extent and anatomic variants that
narrow or clog sinus outflow tracts. In addition, it can also 7.2 Multiplanar Reconstruction
help with the evaluation of anatomical variants that
predispose patients to surgical complications and for image Spatial intelligence [41] is not equally developed in all peo-
guidance during FESS. Surgeons need a description of sinus ple, most have difficulties recreating a three-dimensional
image from only two-dimensional images. These people can
Supplementary Information The online version contains supplementary benefit from brain tricks by attaching the three orthogonal
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_7]. planes of space with the artifice of the dihedral perspective,
three-dimensional recreations, and three-dimensional tangi-
ble models [5, 42, 43]. Bone structures are identifiable in CT
S. Sánchez-Gómez (*) · M. Moreno-Luna · J. M. Maza-Solano scans of primary surgeries, even when affected by inflamma-
J. González-García · J. A. Fernández tory diseases or polyps, so they are the best method for
Department of Otorhinolaryngology, Hospital Universitario Virgen acquiring three-dimensional spatial perceptions, considering
Macarena, Seville, Spain
that they may appear unstructured or absent to varying
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 85

D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_7
Table 7.1  Anatomical structures remaining after failed primary EESSa. Number of patients (percentage in brackets)
86

Gore Khalil Otto and Musy and Chiu and Chu

Baban Nakayama Cantillano Bewick Valdes et al. et al. DelGaudio Ramadan DelGaudio Kountakis Vaughan Ramadan et al.
et al. [5] et al. [6] et al. [7] et al. [8] et al. [9] [10] [11] [12] [13] et al. [14] [15] [16] [17] [18]
Number of patients 24 214b 27 75 66 55 63 127 23 114 70 67 52 265b
(sidesb) (children)
Previous surgeries: 1.42 2.26 1.64 1.97
median (range) (1–3) (1–20) (1–10) (1–6)
Uncinate process 50 29.6 64 64 60.3 37 38.8
Agger nasi cell 83.33 4.5 73.4 64 13 53.5 49 79.1 4.9
Frontoethmoidal cells 40.7 96.8 74 21.9 11.9 31
Supraagger nasi cell 7.7
Frontal supraagger 5.6
cell
Ethmoidal bulla 21.1
Suprabullar cells 12.2 9.2
Frontal suprabullar 20.3 2.7
cells
Supraorbital cells 23.7
Anterior ethmoid cells 79.17 70.4 75 92.1 53 64
Posterior ethmoid 70.83 63 75 96.8 41
cells
Concha bullosa 20.83 9.1
Frontal cells 24.8 45 8
Intersinus frontal cells 25 11.4
Haller cell 7.3 25.4
Onodi cell 8.33 29
Septal deviation 0.29 29.6 12 15.9
Middle turbinate 8,33 14.8 11 17.5 30 78 35.8 3
lateralization
Partial or complete 35 30.2 to
middle turbinate 7.6
resection
Middle meatus 37.5 15 52 27 39
antrostomy stenosis
Middle meatus 51.9 29 47.7 57 14.7
stenosis (scarring) (7.5)
S. Sánchez-Gómez et al.
 Frontal recess stenosis 50 49,3
(scarring)
Frontal recess stenosis 47.7 67 25
(mucosal growth)
Sphenoidal ostium 50 25.9 53
stenosis
Displacement of the 47 68.3 15
maxillary ostium
opening
Maxillary ostium 29
excessive opening
a
EESS Endoscopic endonasal sinus surgery. bNumber of sides. Terminology variability prevents comparison of results
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery
87
88 S. Sánchez-Gómez et al.

degrees in revision surgeries, trauma, or tumor diseases. measure the distance between them, as well as lengths on the
Thin axial CT images must be acquired for presurgical plan- same cutting plane, lines or curves in the case of polygons,
ning using the multirow CT detector with a collimation of and areas.
0.5–0.625  mm displayed simultaneously on a computer Standardized reporting methods use anatomical classifi-
screen. Coronal and parasagittal planes must be reformatted cations to propose checklists to identify and define anatomi-
and linked so that when the cursor moves on one plane, its cal landmarks for ESS [39, 47, 85, 98–101]. We introduced
position is reflected in the other planes. Current multidetec- the “ABCDEF Checklist” to follow a mnemonic rule that
tor computed tomography (MDCT) uses low-dose radiation facilitates sequential, orderly, and complete knowledge of all
protocols (usually 120 kV and 15 mA) while preserving structures [102], rather than one oriented only to structures.
image quality by shortening scanning time and enabling There are practically constant landmarks that help the sur-
post-processing techniques [44]. geon orient himself when many structures are missing or the
CT reports of paranasal sinuses by radiologists generally anatomy seems unstructured: nasal floor, choana arch, sep-
lack relevant content for surgical planning that most tum (or its remnants), lacrimal convexity, medial orbital
otolaryngologists would like to receive [45]. Doctors have floor, maxillary sinus posterior wall, medial orbital wall, eth-
multiple radiological viewers available on their personal moidal fovea, etc. [103, 104] A detailed assessment of surgi-
computers that allow manipulation of original DICOM files cal hazard areas can be carried out using the mnemotechnical
(raw data). This software can perform multiplanar rule “CLOSE”: Cribriform plate (coronal plane), Lamina
reconstructions from a 2D axial projection, reformat into papyracea (coronal and axial planes), Onodi cell (coronal
coronal and sagittal planes, and use volume reconstruction plane), pneumatization of the Sphenoidal sinus (sagittal and
algorithms to generate images with a three-dimensional axial planes), and anterior Ethmoidal artery (coronal plane)
visual appearance (see Table  7.2). Horos® and Osirix® are [105]. Although the development of the frontal sinuses
two of the applications preferred by many otolaryngologists begins at the end of childhood and early adolescence, the
and even many hospital radiology departments due to ease of presence of frontoethmoidal cells is high in the age group
use, multiple functions, ability to generate high-quality between 4 and 15 years, with wide interindividual variability
rendered images, and free of charge. The brightness and [106, 107]. The bone margins of the paranasal sinuses should
contrast of cuts can be altered to more clearly define cell be examined in the three orthogonal planes to document
walls and bone partitions or, on the contrary, to emphasize hyperostosis, destruction, and remodeling.
soft tissues (see Table 7.3).
To standardize the position of the head for measurements,
the axial planes can be defined from a line that crosses the 7.3 Volume Rendering
top of both occipital condyles following the long axis of the
hard palate and the sagittal plane from a line between the Rendered studies based on DICOM images in sagittal and
posterior nasal spine (nasal frontal beak) and the midpoint of coronal planes combined with the cutting tool in the axial
the odontoid process perpendicular to the hard palate. Three-­ plane can create a 3D sequence of the frontal sinus drainage
plane imaging offers more information and provides a corridor that shows the relationships between all cells in the
substantial benefit in surgical planning and performing a frontoethmoidal complex, the uncinate process, and the
surgical procedure on the paranasal sinuses than unique bulla complex inside the frontal recess in a more visually
coronal cuts. Simultaneous multiplanar CT-reconstruction intuitive way.
on a single screen modifies the prior coronal identification of Volume rendering tools in software such as Horos® or
frontoethmoidal cells between 25% [95] and 55% [90] of Osirix® bring about an ROI (region of interest) by developing
cases. Anatomical structures are plotted by scrolling back a virtual volume from two-dimensional images. The surgeon
and forth the marking cross along the axial and coronal or radiologist selects a point or series of points and then
planes and from side to side on the axial plane with the analyzes them independently or relates them to the other
computer mouse or trackpad (see Fig. 7.1). pixels in the image. To do this, two-dimensional polygons
Another advantage of MPR is the removal of metal arti- are manually drawn with a mouse-guided cursor on the axial
facts, visible on the axial plane and absent in coronal and sections on the perimeters of frontal sinus and each of the
sagittal reconstructions. A growing number of browsers are different frontoethmoidal cells. Three-dimensional ROIs are
implementing software modules that use the same image-­ enabled after repeating this action section by section in a
guided surgery functions to perform multiplanar simulations consecutive series of images. You can also apply different
and preoperative renderings on computers outside the cutting tools to these three-dimensional reconstructed images
operating room that can then be used intraoperatively [96], (3D volume rendering). Volumes can also be carried out
including mixed virtual reality systems [97]. In all of them semi-automatically based on different mathematical
you can draw straight lines between pixels in an image and algorithms due to the proximity or similarity of a given value
Table 7.2  Selecting the most commonly used DICOM (digital imaging and communications in medicine) viewers with volume rendering functions
PACS (picture MIP
imaging and (maximum
communication MPR intensity Rapid Hard disk
DICOM system) integration/ (multiplanar projection) Image prototyping space for Processor/RAM
viewer Operating system Cloud reconstruction) [46] fusion Export to system files (.stl) installation requirements Pricing
Horos Mac OS; paid Both available for Y Y Y Picture (JPEG, Y N.A. i5 processor/16 GB Open source
Cloud-based extra fee PNG) and movie RAM
Windows files (AVI)
Osirix MD Mac OS Complete Y Y Y Picture (JPEG, Y N.A. 6 GB RAM Free version (Osirix
integration PNG) and movie Lite) has lesser
files (AVI) features than paid
version
Scopis Mac OS, Available Y Y Y Picture, video, 350 MB i3 processor/2GB Free only for 30 days
medical Windows and data files RAM
PostDICOM Mac OS, 50 GB free, Y Y Y Picture files, N.A. Intel Core i3/2 GB Freeware. Paid version
Windows, cloud-based PACS documents RAM has more cloud storage
Linux, Android, and longer share
iOS duration
3D slicer Windows, Mac Available through Y Y N Picture, video, Y 8 GB Multi-core Freeware
OS X, Linux extensions and data files processor/1 GB
RAM
RadiAnt Windows Available Y Y Y Image and video 5 MB Intel Free version valid for
files, Word and Multicore/512 MB 3 months only
PowerPoint RAM
Mimics Windows 10 Complete Y Y Y Picture, video, Y 15 GB i3 processor/8 GB Free demo
(Mac users can integration and data files RAM
install it using
Boot Camp®)
Navegatium Windows 8.1 or Can integrate to Y Y N N.A. 60 MB i3 processor/4 GB Freeware: not FDA
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery

higher PACS, no cloud RAM approved

storage
Pro-Surgical Windows 8.1 or Not available Y Y N STL and PLY 1 GB i3/ 8+ GB RAM Freeware
3D higher formats
3DimViewer Windows, Mac Not available Y Y Y N.A. Y N.A. N.A. Free license
OS X, Linux
MANGO Windows, Mac Not available Y Y Y N.A. N.A. Intel core/4 GB Free for non-
OS X, Linux RAM commercial use
Sante Windows Mini-PACS Y N N Pictures, movies, 100 MB i3/2 GB RAM Free for 45 days only
DICOMdir available and data files
(continued)
89
Table 7.2 (continued)
90

PACS (picture MIP

imaging and (maximum
communication MPR intensity Rapid Hard disk
DICOM system) integration/ (multiplanar projection) Image prototyping space for Processor/RAM
viewer Operating system Cloud reconstruction) [46] fusion Export to system files (.stl) installation requirements Pricing
Athena Windows 10 Available but in Y Y Y Y 500 MB Intel core/8 GB Free for 1 month only
paid version RAM
Miele LXIV Mac OS X PACS integrated Y Y Y Y 50 MB Intel processor Free for non-
commercial use
ORS Visual Windows Not available Y Y N Not available on N.A. Intel processor/2 GB Free version has lesser
Lite free version RAM features than paid
version
Onis Viewer Windows Up to 15 patients Y Y N Picture and 30 MB DualCore Free version is limited
annotation export processor/1 GB to 15 patients
RAM
Gingko Windows, Mac Not available Y Y N Picture file 1 GB Intel Free version has lesser
CADx OS X, Linux export processor/512 MB features
RAM
Weasis Windows, Mac PACS integration Y Y N Picture file N.A. Intel processor/2 GB Free for non-
OS X, Linux export RAM, JAVA runtime commercial use
environment 8
Yakami Windows Available Y Y Y N.A. 256 MB Intel processor/2 GB Free for non-
DICOM RAM commercial use
DICOM Digital imaging and communications in medicine, PACS picture archiving and communication system, MPR multiplanar reconstruction, MIP maximum intensity projection [46]
Y yes, N no, N.A. not applicable
S. Sánchez-Gómez et al.
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 91

Table 7.3  Step-by-step multiplanar reconstruction method. Based on the “ABCDE” checklist [47] and the International Frontal Sinus Anatomy
Classification (IFAC) [48]
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Agger nasi cell • Identifying the ANC Coronal • First cell that appears • Most of the ANC is anterior to • Remnants after first
(ANC) is the surgeon’s first in an anterior-to- the UP in parasagittal scans failed sinus surgery
step in planning FS posterior scrolling. but the posterior half of the range from 4.5% and
surgery Posterior to the ANC is intimately related to 83.33% of cases (see
• The ANC spatially lacrimal bone, the upward extension of the Table 7.1)
shapes the FR and anterior and superior UP. Posterior medial wall of • It is convenient to
the FSO [49] to the insertion of the the ANC can be an rotate the parasagittal
• Very constant, but at MT into the lateral indistinguishable part of the plane to an alignment
risk of iatrogenia in nasal wall, anterior vertical portion of the UP on similar to that of the
5–10% of patients to the free edge of the coronal plane. UP cannot actual endoscopy to
without ANC [2, 50] the UP, and anterior be seen in the anterior half of promote spatial
• The ANC volume to the head of the the ANC in coronal cuts perception in three
directs the UP upper MT • The spatial relationship of the dimensions of the
insertions ANC with the nasolacrimal ANC in relation to its
• Upper UP duct, sac, and orbit, as well as neighboring structures
attachments onto the the distance between ANC and and for depth of field
MT and SB promote the anterior wall of the EB, • The ANC can be
medial or (delimiting the semilunar confused with a
posterolateral hiatus) and between both terminal recess when
drainage of the FS structures and the lateral wall viewed only on the
• The most common of the nostril to delimit the coronal plane. The
location of the ANC ethmoid infundibulum, can be terminal recess opens
ostium is inferior on assessed in axial projection downward to form a
the posterolateral • Parasagittal scans determine blind pocket, while the
wall and may be the height of the ANC along ANC has a lower bone
confused with an the ascending process of the wall
open space inside the maxilla. The thickness of the
nasal cavity [51] NFB is related to the volume
of the ANC. The larger the
ANC, the larger the
anteroposterior FSO
• The degree of pneumatization
of the ANC instead of the
number or site of the cells
better determines endoscopic
accessibility to the FS
• The most anterior part of the
MT fuses with the AANC
inferiorly to form the so-called
axilla
Supra agger cells • It may be unique or Parasagittal • Anterior-lateral • An anterior-based cell above • The surgeon will be
(SAC) multiple ethmoidal cell, the ANC that has entered the able to securely open
• The number of SAC located above the FS pneumatizing into the FS to the roof of the ANC
should be identified ANC not be located above the NFB is after evaluating the
in parasagittal planes pneumatizing into therefore, by definition, a distance between this
and if any contain the FS SAFC upper wall and the
parts or all of their • The question of whether a cell posterior aspect of the
volume within the FS reaches the FS can be FS following the line
(supraagger frontal answered by observing coronal extending the NFB
cell, SAFC) CT and seeking bone into parasagittal
continuity through the base of sections
the FS. This continuity is
because CT is on a plane that
cuts the NFB, and it is the
NFB bone that forms this
continuity
(continued)
92 S. Sánchez-Gómez et al.

Table 7.3 (continued)
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Uncinate process • The remains of the Coronal • The image should be • Two-dimensional images show • It is important to
(UP) upper UP insertion scrolled anteriorly to that the LP is the most identify the distance of
are found in up to posteriorly to follow common site of a unique the UP to the medial
30–64% of failed and the UP upwards from superior UP attachment [51, wall of the orbit and
revision surgeries its identification at 54], but 3D imaging its separation relative
(see Table 7.1). This the natural ostium of determines multiple to the medial wall of
is an indication that the maxillary sinus simultaneous insertions in SB, the ANC
primary surgeries LP (actually the orbital plate • Cursor simultaneous
should be performed of the frontal bone) [55] and displacement in axial
correctly MT up to 68% of the sides, slices allows
• Variations of the 9 only to the LP and the SB at evaluating the
types of SAUPs [52] 7%, to the LP and MT at 13%, posterior border of the
affect FSO to MT and SB by 3%, only to UP along the entire
dimensions and NFB the MT by 5%, and only to the hiatus semilunaris and
size LP at 1% [51] its relationship with
• SAUP is a landmark • The upper attachment of the the anterior aspect of
for the location of UP at the junction of the the EB and SBC up to
the FSDP [53]: in the medial wall of the ANC with the FR
middle meatus the UP on the LP corresponds • The number and
(75–89.9%), lateral to the “vertical bar,” an attachment structures
in the infundibulum endoscopic reference useful of the upper end of the
(10.8–23%) or both for identifying access to the FS UP should be
(3%) [56] identified in the three
• Multiplanar images identify planes
the fusion of SAUP and EB on • The superior insertion
the superior aspect of the of the UP does not
hiatus semilunaris, known as always move medially
the anterior ethmoidal genu, toward the SB and
directing the FSDP medially in even to the MT when
77% of cases [57] the ANC is larger [49,
• The anterior portion of the UP 58–60]
forms the lateral wall of the • Preoperative
FR when attached to the LP or identification of acute
ANC; FRDP is channeled angle with LP and
directly into the middle lateral orientation
meatus, and the ethmoid prevents iatrogenic
infundibulum ends as a orbital penetration
blind-ending recess, which is
called the recessus terminalis.
The UP forms the medial wall
of the FR when it attaches to
the SB or the MT and, in this
case, the secretions are
directed into the ethmoid
infundibulum before moving
to the middle meatus
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 93

Table 7.3 (continued)
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Anterior ethmoid • Found in more than Coronal • Look for the AEA by • A well pneumatized SOEC • The coronal bony
artery (AEA) 98% of cases behind scrolling makes the AEA lie lower than notch on the medial
the second lamella anteroposteriorly in the SB, making it more wall of the orbit
(anterior face of the the coronal cuts in susceptible to injury during corresponding to the
EB or of the SBC/ the funnel-shaped surgery [63] anterior ethmoidal
SBR), the intact EB bony notch with a • The AEA is separated from SB foramen may be
technique provides a narrow, distal end in 40-80% of cases, to which it observed in the
consistent and safe directed medially is bound by a thin mesentery frontoethmoidal suture
reference and that forms on the • The location of AEA is in parasagittal planes
protects the AEA superomedial wall of classified as Grade I when in Grade I or inferior
from damage during the orbit, between included in SB; Grade II run in Grades II–III
FS approach the medial rectus and below SB and considered • AEA is more likely to
• The distance superior oblique prominent; Grade III refers to run freely in the
between the AEA muscles AEA that travels freely at a ethmoid sinus as
and the posterior distance from SB [64] Keros level increases,
wall of the FR is • The anteroposterior length of when the height of the
11 mm (range 6–15 the lateral lamella of the lateral lamella of the
mm) [61] cribriform plate should be cribriform plate is
• The anterior measured by combining it with higher and the OF is
ethmoidal sulcus is a the Keros and determining deeper and the roof of
bone disruption on spatial risk: Type I, 6–10 mm; the ethmoid is
the lateral wall of OF Type II, 11–15 mm; Type III, higher[67–69]
[62] where the AEA 16–20 mm [65] • The combination of
enters the OF • When separated from the SB, coronal, axial, and
the artery runs into a SBR or sagittal images reports
SBC the thickness of the
• The direction of the AEA is bone wall surrounding
checked from posterolateral to the artery
anteromedial in axial cuts by • Greater distance
placing the cursor at the exit between SB and AEA
point of the artery from the when Keros is higher
orbit • Keros Grade 2 or 3 is
• The simultaneous position of 17.3 times more likely
the cursor in the parasagittal that the anterior
sections indicates the greater ethmoid canal will be
or lesser separation of the suspended within a
artery from the SB and its mesentery [70]
position relative to the second
and third lamellas [66]
Ethmoidal bulla • The EB is present Parasagittal • The largest anterior • EB consists of a differentiated • Occasionally under- or
(EB) almost constantly and inferior ethmoid bony lamella in all cases with undeveloped EB in
and commonly cell a variable degree of 8% of cases
comprises a single development and • SBC and SBR are
cell opening into the pneumatization separated by a small
superior semilunar • Posteriorly, it may fuse at a but consistent tissue
hiatus or retrobullar variable distance with the bridge that is projected
recess basal lamella of MT from the basal lamella
• Variations in the • Superior wall of SBC and SBR to the superior aspect
suprabullar area are is the SB, and its anterior of the EB and LP. An
frequent and include border does not cross the FSO additional projection
simple SBC, SBR, into the FS of the basal lamella
frontal bulla cells, • Although some authors found within the retrobullar
and SOEC that EB lacks a distinct recess is projected
posterior wall and is therefore onto the LP [73]
not a separate cell but rather a
bony lamella with an air space
behind it [71], typically, SBC
and SBR are separated, and
each has a corresponding
pneumatization that does not
connect with neighboring cells
or structures [72]
(continued)
94 S. Sánchez-Gómez et al.

Table 7.3 (continued)
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Supraorbital • Pneumatization of Coronal • Pneumatizes over the • Parasagittal slices are very • The presence of FS
ethmoid cell the orbital plate orbit (coronal) and useful for identifying that the multiseptations in CT
(SOEC), lateral to the most enters the FR origin of the SOEC is indicates the possible
suprabullar frontal medial plane of the posterior and lateral above-sitting the EB or the presence of SOEC
cell (SBFC) LP to the true FS (axial) SBC or the SBR [74]
• Posterior cells that • FBC might look similar in • SOEC may serve as a
push the drainage sagittal and axial CT images to consistent landmark
pathway anteriorly SOEC, but differences in for locating the AEA
(IFAC classification) coronal CT images can be [75]
identified • Simultaneous axial
• While Type III FC, FBC, or and parasagittal
IFSC are usually medial to the multiplanar slices can
FS, the SOEC is usually lateral help differentiate
to the FS SOECs from FS itself
• The SOEC recess is located and other
posteriorly and laterally to the frontoethmoidal or
FSO, and the AEA is located frontal cells, which
posteriorly to the SOEC can be confused if
• The most prevalent type of only coronal slices are
suprabullar pneumatization is evaluated [76]
Type 2 (tier of cells above the
EB, confined in the ethmoid
sinus, 40.1%), followed by
Type 1 (single air cell above
the EB, confined in the
ethmoid sinus, 24.3%), Type 3
(single or a tier of cells above
the EB, pneumatizing cephalad
into the FS, 23.3%), and Type
0 (superior extension of the EB
directly opens onto the SB of
the ethmoid roof; no
suprabullar space or cell is
present, 12.4%) [73]
• The SB forms the posterior of
the SBFC
Middle turbinate • MT is a thin scroll Coronal • The best plane to • The basal lamella of the MT is • Excessive or
(MT) sheet of bone formed identify the head of a thin bony plate that is part of inaccurate handling of
from the medial the MT and follow the ethmoid infrastructure. It the anterior attachment
portion of the its upper insertion to has three portions. The vertical may lead to iatrogenic
ethmoid bone the cribriform plate portion of the basal lamella cerebrospinal fluid
• It lies inferomedial attaches to the cribriform leak. Observing its
to the air cells of the plate. The middle and posterior superior insertion can
anterior ethmoid and portions extend laterally to predict the fragility of
attached vertically to join the LP, thus dividing the MT insertion into the
the cribriform plate air cells of the anterior cribriform plate
superiorly and to the ethmoid from the air cells of • In case of revision
LP laterally through the posterior ethmoid and the surgery, it is important
a bony strut, the posterior margin of the basal to identify the
basal lamella lamella attaches to the antero-superior part of
perpendicular plate of the MT as it may be the
palatine bone only recognizable
• The basal lamella is best structure
displayed in three-dimensional
models and sagittal and axial
CT images
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 95

Table 7.3 (continued)
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Frontal sinus (FS) • The FS has a great Coronal • The pneumatization • Type 1, pneumatization • High inter- and
anatomical, of the FS, the (aplasia and hypoplasia): intra-individual
volumetric, and position of the FSDP minimal or no pneumatization variations in the size,
dimensional and adjacent cells, below the supraorbital line; shape, position of the
variability and can anteroposterior and Type 2, pneumatization IFSSC, and the
reach enormous mediolateral (middle): frontal sinus limited presence of other
proportions, with diameter should be to medial to the midorbital septations and cells
projections into the determined line. Type 3, pneumatization
zygomatic (hyperplasia): frontal sinus
supraorbital recesses extending lateral to the
and parietal bones midorbital line [77, 78]
• FS pneumatization patterns
can be defined by 3D
CT-based volumetry [79]
Nasal frontal beak • Composed of the Parasagittal • The NFB forms the • A large agger nasi and • The larger the
(NFB) confluence of the floor of the FS. ANC pneumatization of frontal diameter between the
proper bones, the and NFB form the ethmoidal cells will often NFB and the posterior
frontal processes of anterior limit of the reduce the size of NFB, edge formed by the
the maxillary FR whereas the absence of these SB, the easier the
maxillae, the nasal cells would produce a thick surgical dissection
spine, and the medial beak [49] • The thickness and
orbital processes of • The posterior border of the length of the NFB
the frontal bone NFB was found to be anterior predict the need to
to the OF on the left and right drill to outline the
of the midline in 100% of anterior limit of the
patients and on the midline in sinusotomy in the FSO
98% [80] openings
• The surgeon should
appreciate the transition
between FS and FR in
coronal and sagittal cuts [81]
Frontal recess • FR typically refers to Parasagittal • It is the space • The roof of the FR consists of • FR patency depends
(FR) “passive space” posterior to the NFB the FSO anteriorly and fovea upon several factors,
surrounded by and ANC up to the ethmoidalis posteriorly including (1) the
frontal cells bulla lamella or runs • The ANC, SAC, and SAFC are superior articulation of
• FR is the space into to the basal lamella positioned anteriorly to the the UP, (2) the ANC,
which the frontal of the MT in cases of FR; the EB, SBC, SBFC, and (3) the presence or
sinus drains and SBR SOEC posteriorly; and the absence of frontal
corresponds to the FSC medially [83] cells, (4) the SOEC,
most anterior- • In coronal cuts, the medial and (5) the bulla
superior part of the wall of the FR is formed by lamella
middle meatus [55] the vertical lamella of the MT • Killian first used the
and the supero- and lateral wall of the OF and term “frontal recess”
anterior prolongation the lateral wall is formed by in 1903; later, Van
of the ethmoid the LP, lacrimal bone and the Alyea’s writings
infundibulum [82] posterior wall by the upward extensively described
• FR is usually continuation of the anterior the patterns of
occupied by a face of the EB or an SBC or pneumatization within
number of cells that SBR the FR
affect the direction • The FR opens inferiorly either
and position of this to the ethmoid infundibulum
drainage pathway or to the middle meatus
depending on the UP
configuration. When the
anterior portion of the UP
attaches to the SB, the FR
opens to the ethmoid
infundibulum and from there
to the middle meatus through
the hiatus semilunaris. When
the UP attaches to the LP
instead of the SB, the FR
opens directly to the middle
meatus [84]
(continued)
96 S. Sánchez-Gómez et al.

Table 7.3 (continued)
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Frontal sinus • Some authors prefer Parasagittal • The narrowest area • The anterior-to-posterior • The SB junction of the
isthmus (FSI) [14], the term isthmus of the transition zone diameter is the distance second lamella and
frontal sinus instead of ostium or from FS to FR with between the most posterior suprabullar
opening (FSO) opening to highlight its anterior edge projection of the NFB to the pneumatization can be
[85] its three-dimensional formed by the NFB junction of FS posterior wall used as another
spatial configuration and the posterior and the anterior ethmoid roof landmark to identify
rather than the edge formed by the that is the junction of the the posterior opening
two-dimensional SB anterior wall and the inferior of the FS and AEA
configurations of the • The FSO is oriented wall of the anterior cranial • In a specified sagittal
maxillary and nearly perpendicular fossa CT slice, a vertical line
sphenoid ostia to the posterior sinus • The transverse diameter is best can be drawn through
• The contours of the wall, indented evaluated on the coronal plane the posterior edge of
FS and FR have been anteriorly by the • The lateral boundary of the the NFB along its
described as forming NFB FSO is the LP and the medial vertical axis and a
an hourglass, the boundary, the upward second line can be
narrowest part of extension of the vertical placed at the return
which is taken as lamella of the MT and the point of the
FSO lateral wall of the OF SB. Depending on
• The location and • The FSO area can be whether the first line is
diameter of the FSO determined by rendering a posterior or anterior to
are directly related to slightly tilted image upwards in the second line, the
the position of the the A-P plane on an axial plane. FSO is rated as
NFB and the upturn An axial plane image is created positive and more
point (deflection on a plane parallel to the plane easily accessible or
point) of the anterior used to measure the FSO negative and therefore
SB diameter. FSO margins are more challenging,
outlined using the software’s respectively. If both
pencil function. The software lines overlap, then
then calculates the area of the there exists a neutral
FSO rating (0) [86]

Frontoethmoidal • Air cells that Coronal, • The key to safe • Posterior wall of ANC, SAC, • FEC have one feature
cells (FEC) encroach on the parasagittal surgery on FR is a and SAFC is a free partition in common: their
frontal recess or clear understanding on the FR and is not SB posterior wall is the
extend into the FS of FEC’s 3D • The SAFC may extend anterior boundary of
[87] anatomy, so every significantly into the FS and the FR
• Anterior cells that cell seen first in may even reach the roof of the • SAFCs are often
push the FSDP sequential coronal FS indistinguishable from
medial, posterior or scans should be • The lateral FEC is an the former K3 cells on
posteromedially identified in anatomical variation that coronal CT scans
(IFAC classification) parasagittal scans cannot be classified as anterior • The pneumatized
or posterior [88] using the structures that
classifications of Lee et al. encroach on the FR
[89] or Wormald et al. [48] and extend from the agger
pushes the FSDP nasi, EB or the
anteromedially terminal recess of the
ethmoidal
infundibulum. If these
cells do not extend
into the frontal sinus,
they are called
"anterior ethmoidal"
cells; if they do enter
the frontal sinus, they
should be termed
“frontoethmoidal”
cells [85]
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 97

Table 7.3 (continued)
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Frontal sinus • The FSDP is Axial • FS should be clearly • FSDP, FSO, and FR are • Left-right asymmetry
drainage pathway systematically identified in high modified, shifted, and within the same
(FSDP), frontal located between the scans and scrolled narrowed by the pneumatized patient occurs in up to
sinus outflow tract first and second from the top down agger nasi, anterior ethmoid 46% of patients,
(FSOT) lamellae (cranial to caudal) cells, frontal cells, supraorbital underscoring the
• FSOT is described as • FSDP can be plotted ethmoid cells, and surrounding importance of
an hourglass that around cells in FS anatomical structures (vertical studying each side
consists mainly of and FR and insertion of the UP and bulla independently during
three structures: the correlated with lamella) presurgical planning
frontal sinus FSDP seen in • FSDP is a narrow passageway • While preoperative
infundibulum, coronal and bounded anteriorly by the recognition of cell
ostium, and recess parasagittal scans ANC, laterally by the orbit, types is important,
• The FSDP is well [91] and medially by the MT knowledge of the
delineated in the • In most cases this duct-­shaped FSOT’s position
three orthogonal structure has no bone walls of relative to endoscopic
planes. However, it its own, but the walls are landmarks is vital for
looks good on the formed by the close safe FS surgery or
parasagittal plane as relationship of several different balloon dilation. It is
an hourglass shape. anatomical structures that form important to prevent
The “waist” of the the boundaries of what is failed attempts to
hourglass known as FR [92] cannulate the FSO that
corresponds to the • A systematic analysis with 3D may result in mucosal
FO located at the CT microanatomy can add rupture, erroneous
level of the supplements and refinements placement within
NFB. The FS lies to current classifications and cells, or inadvertent
above the waist and nomenclature of the bleeding or injury to
the FR can be frontoethmoidal transition critical structures [94]
identified below the region [93] • CT stereoscopic
waist [90] imaging (3DCTSI)
provides improved
display and delineates
three defined complex
“spaces,” the Frontal
Sinus/Frontal Recess
Space, the
Infundibular Space of
the Ethmoid Uncinate
Process, and the
Ethmoid Bulla Space
(FSRS, IS-EUP, EB),
none of which has
been adequately
described with the
“cell” terminology
Interfrontal sinus • Drains into one FR Coronal • It is associated with • This cell may be confirmed in • When viewed on
septal cell, or the upper bony end axial views coronal CT scans,
intersinus septal of the NS and • Its presence can displace the IFSSC can be
cell (IFSSC) posterior to the FSDP laterally confused with Kuhn
quadrangular Type 3 or 4 cells
cartilage
(continued)
98 S. Sánchez-Gómez et al.

Table 7.3 (continued)
Priority CT
Anatomical Main concepts for plane for
structure planning recognition Identification Analysis Tips and pearls
Olfactory cleft • OC is bound Coronal • The lateral wall of • The vertical distance between • Asymmetric Keros
(OC) and olfactory superiorly by the the OF is in the the lamina cribrosa and the should be checked
fossa (OF) cribriform plate, posteromedial and fovea ethmoidalis represents
medially by the superior region of the the depth of the OF, with the
upper NS, laterally FR vertically oriented lateral
by the top of the lamella as its lateral edge
medial aspect of the • The height of the lateral wall
MT and superior of the OF depends on the level
turbinate of the cribriform plate. Keros
• OF contains the has described three classic
olfactory bulbs and heights: Type I, less than or
tracts and is bound equal to 3 mm in depth; Type
inferiorly by the II, 4–7 mm; and Type III,
cribriform plate, greater than 7 mm in depth
laterally by the
lateral lamella of the
cribriform plate and
medially by the
crista galli
ANC agger nasi cell, AEA anterior ethmoid artery, CT computed tomography, EB ethmoidal bulla, FS frontal sinus, FEC frontoethmoidal cells,
FSDP frontal sinus drainage pathway, FSI frontal sinus isthmus, FSO frontal sinus opening (=frontal sinus ostium), FSOT frontal sinus outflow
tract, IFSSC interfrontal sinus septal cell, LP lamina papyracea, MT middle turbinate, NFB nasal frontal beak, NS nasal septum, OC olfactory cleft,
OF olfactory fossa, SAC supra agger cell, SAFC supra agger frontal cell, SB skull base, SBC suprabullar cell, SBFC suprabullar frontal cell, SOEC
supraorbital ethmoid cell, SBR suprabullar recess, UP uncinate process

of a selected pixel by placing a seed (dot) at a specific loca- It is important to identify the route of the anterior eth-
tion in the CT image and segmenting by expanding or grow- moidal artery through the roof of the nostril using ROI points
ing that seed through the rest of the cuts. The created ROIs in order to visualize them in the renders and virtual endos-
can be extracted and displayed independently of the 3D vol- copy and relate it to the ostium of the frontal sinus. It is pos-
ume rendering or along with the other structures, as if it were sible to modify the contrast and brightness of the model to
a schematic image of the frontoethmoidal complex. Color make the walls of the cells of the bullous complex transpar-
command options with pre-defined and even custom colors ent if the artery is inside it.
bring great realism to the resulting preparations for analyz- One of the most important steps in preoperative planning is
ing individual anatomy, as well as the improvements made the identification of the upper insertions of uncinate process,
using accurate measurements of length, area, and volume. whose remnants between 30 and 64% of primary surgeries are
The volume rendering of the frontal sinus ROIs (fronto- the most common cause of frontal sinus reoperations. This
ethmoidal cells, ethmoidal bulla complex, middle turbinate, structure is best visualized in three-­dimensional reconstruc-
uncinate process, and frontal recess) begins by placing the tions from a posteroinferior and inferomedial view, thus rec-
cursor inside the frontal sinus on one side on some of the ognizing the different insertions and spaces it generates, as
most axial upper sections. From this point on, the different well as its exact relationship with the frontal sinus opening.
ROIs are drawn in successive axial sections during cranio-
caudal displacement using the tools of a brush or pencil or by
means of growth regions assigning different names and col- 7.4 Surface Rendering
ors to each region or space (see Fig. 7.2). The frontal sinus
drainage pathway can be found medial or lateral to the cells Surface rendering creates a mesh of polygon surfaces of
depending on the presence or absence of the different fronto- structures based on their Hounsfield units, formed by
ethmoidal cells, along with their degree of pneumatization, triangles and their vertices, that allow you to individualize
as well as anterior or posterior to them, although in 75% of layers of tissue that share the same radiological density. They
cases it runs posterior and medial to the agger nasi cell. can be exported as .stl files for three-dimensional viewing
Wormald’s proposed 3D block outlining to schematically and modification with surface mesh editing software such as
understand the composition of the frontal recess and other Blender® or Meshmixer® and even printed with a 3D printer
anatomical structures in the region can be taken as a refer- (see Fig. 7.4). The modification options are unlimited, pro-
ence and can be performed by the Horos® or Osirix® soft- viding detailed and realistic information on the arrangement
ware by manually assigning the actual volumetric shape to of different structures and their anatomical relationships.
each structure [91] (see Fig. 7.3 and Video 7.1). These reconstructions form the basis of virtual surgeries.
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 99

a b c

d e f

g h i

Fig. 7.1 (a–f) Use of two-dimensional multiplanar images in axial marks the same point in the 3 planes. (g) Plain rendered image. (h)
(a–d), coronal (e), and parasagittal (f) cuts to draw the different cells of Adding ROI (regions of interest) to the rendered image. (i) ROI rendered
interest and process them with Osirix® for volumetric recreations (g–i). image processed with mesh. Cells are identified and colored in 2D
The relationship between the different structures is best seen in (g–i) images prior to being processed and rendered. FS frontal sinus, purple;
acquiring a three-dimensional aspect that helps the surgeon to better SBC suprabullar cell, blue; IFSSC interfrontal sinus septal cell, green;
understand the anatomy of the region. (a–c) Axial cuts from a higher SAC supraagger cell, dark green; EB ethmoidal bulla, gray; ANC agger
location to a lower one and (d–f) is a multiplanar cut where the cross nasi cell, red

points the way and identifies both target and “anti-targets”

7.5 Augmented Reality structures, or structures to avoid, reducing the workload dur-
ing surgery across all subscales of the NASA-TLX index
The surgeon can approach anatomical structures more safely (effort, frustration, mental demand, temporary demand, and
by applying augmented reality during preoperative planning performance). It is not necessary to directly visualize the
and even merging the augmented reality system with surgical structures to be removed and those to be avoided, since
endoscopic vision, providing the surgeon with visual cues as augmented reality complements the eye vision [111]. The
tracking instruments are introduced through planned virtual Scopis® Navigation software is based on the Wormald
orifices and passageways [108–110]. Augmented reality “building blocks” technique [91] to delimit the cells in the
100 S. Sánchez-Gómez et al.

a b c

d e f

g h i

Fig. 7.2 (a–i) Presurgical study using two-dimensional images of axial agger nasi cell (ANC), ethmoidal bulla (EB), uncinate process (UP),
cuts in the cranio (a) caudal (i) direction processed with Osirix® middle turbinate (MT), and maxillary sinus (MS) is better appreciated
following the frontal sinus drainage pathway (drawn in green). The than when using the original grayscale DICOM images
relationship between the frontal sinus (FS), supraagger cell (SAC),

frontal recess using colored prisms and manually draw the with endoscopic images that show the surgeon where to pro-
frontal sinus drainage corridor in relation to these prisms. ceed with the surgery.
The Scopis® Augmented Reality module is useful when tar- Manual 2D segmentation is often cumbersome and, in
geted help is needed to learn the shape of frontoethmoidal practice, eludes the detailed annotation of the multitude of
cells or to perform presurgical rehearsal of the intervention structures that would be of interest during endoscopic
or perform image-guided surgery. Recently, Karl Storz’s endonasal surgery. Automated 3D segmentation of image
NAV1® Sinus Tracker™ software has been introduced, datasets is currently in development and will allow detailed
which also integrates new augmented reality elements to preoperative plans to be used in augmented reality IGS [112].
allow the surgeon to draw the so-called surgical pathways in A novel technique that uses augmented reality-enhanced
the CT series. These pathways can be fused intraoperatively surgical navigation has been described by holographically
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 101

a b

POSTERIOR

LATERAL

MEDIAL
ANTERIOR

Fig. 7.3  Options for drawing cell volumes with Osirix® in two differ- region, being able to move them in the three planes of space with the
ent cases of surgical planning of left frontal sinuses. (a) Removing the mouse or trackpad. (b) Volumetric rendering with regions of interest
structures of interest to display them independently of the rest of the surrounded by other structures in the region

a b

Fig. 7.4  Process of creating three-dimensional images with great real- image. ANC agger nasi cell, EB ethmoidal bulla, FS frontal sinus, FSDP
ism. (a) Application of polygon meshing with Meshmixer® to files gen- frontal sinus drainage pathway, IFSSC interfrontal sinus septal cell,
erated with Osirix®. (b) Final 3D modeling after rotating the previous SAC supraagger cell, SBC suprabullar cell
102 S. Sánchez-Gómez et al.

visualizing the patient’s frontal anatomy in different layers region [116, 117]. Three-dimensional tangible models of
(skin surface, bone surface, and frontal sinus cavity) with individual patients facilitate volume recreation in the sur-
augmented reality goggles to perform osteoplastic approaches geon’s mind prior to surgery and complement the rest of the
external to the frontal sinus [113]. imaging systems during the operation. Planned approaches
based on multiplanar images, 3D volume reconstructions,
and augmented reality can be modified in the operating room
7.6 Stereolithography when the surgeon compares rapid prototypes to the actual
surgical field [118] (see Fig.  7.5). The highest quality of
Stereolithography or 3D printing of rapid prototypes has printing materials using resins/ thermoplastic filaments/pow-
proven useful in surgical planning in addition to teaching and ders favors a natural three-­dimensional impression and is
training [114, 115] with special interest in the frontal sinus more acceptable to users [119–121], with polycarbonate

a b c

d f

Fig. 7.5  Surgical planning with Osirix® of a case of posttraumatic left processing of 3D images depending on the interest of the areas to be
frontal mucocele caused by obliteration of the frontal sinus drainage displayed; (f–h) stereolithographic [SLA] rapid prototype of selected
pathway with a bone fragment and disappearance of bone elements volumes based on DICOM images and Osirix® .stl files in inferior,
from the left outer frontal table and orbit roof; (a–c) multiplanar superior, and front views; (i–k) operating theater use of sterilized SLA
identification of the point of interest by the axis cross, which can be rapid prototype to help the surgeon orient himself spatially. Solid and
displayed simultaneously on the sagittal, axial, and coronal planes and thick white arrow: fragment of frontal-ethmoidal bone; thin white
can be moved at will; (d) surface rendering, (e) volume rendering and arrow: fragment of orbital bone
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 103

i k

Fig. 7.5 (continued)

being the material that has the best properties to simulate faces of endonasal structures with their recesses, bone parti-
the craniofacial bone [122]. Stereolithographic models sig- tions, meatus, cell ostia, and frontal outflow tract without
nificantly reduce the workload of endonasal endoscopic limiting the angulation and displacement of instruments
surgery on the NASA-TLX scale [118, 123, 124]. used in conventional endoscopy. The visual approach of the
Stereolithography makes it possible to have 3D prints of frontal opening is useful both from the middle meatus and
autologous bone models for the reconstruction of cranial looking with the camera upwards as well as from a rear
structures using printable files using the Standard position inside the nostril or from above inside the frontal
Tessellation Language (stl.). Stereolithographic models are sinus [51]. The camera “eye” is displayed simultaneously
used for the production of titanium meshes, the adaptation with a cursor on each of the corresponding triplanar views
of reconstruction plates for the surface of cranial or septal (see Fig. 7.6 and Videos 7.2 and 7.3). Similar to augmented
perforations, the manufacture of custom-made implants, or reality, structures that are not visible in the actual endo-
as scaffolds to direct the development of the patient's tis- scopic view due to overlapping tissue can be displayed in
sues on them [39, 125–128]. The current trend points to the the virtual image, including proximity alerts to vital struc-
combination of 3D reconstruction display systems plus vir- tures. Surgical instruments can be tracked and displayed by
tual reality and augmented reality with 3D printed models performing a complete mapping of both frontal recesses in a
[129], even within mobile phones [130]. series of horizontal and vertical rows, where vertical refers
to openings in an anterior-to-posterior direction and hori-
zontal refers to openings in a medial-to-lateral direction
7.7 Virtual Endoscopy [131]. It is used for both preoperative planning and intraop-
erative orientation, as it corresponds to the actual endo-
Radiological viewers such as Horos® or Osirix® allow vir- scopic view. Virtual endoscopy has been shown to be
tual endoscopies to be performed from DICOM images. especially useful for identifying the upper insertions of the
Virtual endoscopy offers highly realistic images of the sur- uncinate process and for visualizing the frontal sinus drain-
104 S. Sánchez-Gómez et al.

a b

c d

Fig. 7.6  DICOM image processing with Osirix. (a–c) Simultaneous to the frontal sinus isthmus (FSI). EB ethmoidal bulla, FS frontal sinus,
triplanar images of the case presented in Fig. 7.1. (d) Virtual endoscopic IFSSC interfrontal sinus septal cell, MT middle turbinate, SAC
view corresponding to (a–c) cuts. The pink circle corresponds to the supraagger cell, SBC suprabullar cell, UP uncinate process
position of the virtual camera and shows the relationship of structures

age corridor at the middle meatus by directing the virtual 7.8 Virtual Surgery
endoscope toward the free edge of the vertical portion of the
uncinate process and placing it in front of the anterior wall Endonasal endoscopic surgery simulators have been devel-
of the ethmoidal bulla complex, outside the vertical lamina oped in recent years as a virtual surgery method for training
of the middle turbinate. Virtual endoscopy will be inserted and for presurgical rehearsal on CT treated images of real
into the terminal recess when the uncinate process is inserted patients [133], as spatial orientation is the most difficult sur-
higher into the lamina papyracea in its entirety or with some gical subtask to perform and with a longer learning curve
insertion [132]. [134] (see Fig. 7.7). Workstation computers have also incor-
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery 105

porated haptic devices that give the surgeon instant tactile

sensory feedback on the resistance properties of tissue, bone
hardness, and tension in instruments while exerting force on
all three axes of space to the distal tip of the surgical tool,
simulating the haptic signals perceived during surgery.
Table  7.4 shows the most commonly used endoscopic sur-
gery simulators. Preoperative rehearsal of frontal sinus sur-
gery through virtual simulation is one of the procedures that
benefits surgeons most to improve their surgical skills and
confidence during surgery, regardless of the help provided by
image-guided surgery [144]. Technological advances tend to
produce as realistic 3D recreations as possible, resorting to
photogrammetric logging processes based on contours that
complete a photograph [145] or transferring to the surgeon
more and more sensations of photorealism in the recreation
of the mucosa [141]. The technology is able to fuse the dis-
play images in 2D, 3D, and augmented reality, allowing the
surgeon to move images and renderings with his hand “in the
air” outside and inside the operating room without the usual
Fig. 7.7  Visualization of the capture of one of the steps of virtual sur- screens [146] (see Fig. 7.8).
gery from the CT DICOM images of a real patient. The upper third of
the UP has been partially removed to show how the UP is part of the
medial face of the ANC and the SAC.  Virtual surgery is ideal for
identifying the upper insertions of the UP and subsequently avoiding
during actual surgery leaving remains inadvertently. Only the anterior
face of the EB is preserved to appreciate the configuration of the hiatus
semilunaris and its attachment to one of the upper insertions of the UP
to form the anterior ethmoidal genu. Other upper insertions of the UP
are to SB and LP. ANC agger nasi cell, EB ethmoidal bulla, FSI frontal
sinus isthmus, IFSSC interfrontal sinus septal cell, SAC supraagger cell,
UP uncinate process
Table 7.4  Selection of validated virtual simulators for endoscopic sinus and skull base surgery
106

Application and main

Simulator Year focus Hardware and haptic device features Software features
Endoscopic Sinus Surgery Simulator (ES3; Lockheed 1997 • FESS • Workstation simulation platform (Silicon • Three modes (novice, intermediate,
Martin, Bethesda, MD) [135] • Surgical training Graphics, Mountain View, CA) and advanced) associated with task
• PC-based haptic controller complexity
• Unilateral haptic manipulators • The most extensively validated
• Haptic feedback on instruments (except simulator
for the endoscope)
• A mannequin’s head
Nasal Endoscopy Simulator (NES; Regensburg 1997 • FESS • Electromagnetic tracking system (sensors • Real-time collision detection and
University Hospital, Regensburg, Germany) [136] • Surgical training on the endoscope, real surgical simulation of tissue deformation
instruments, and mannequin head)
• No haptic feedback
• A mannequin's head
Dextroscope (Volume Interactions, Singapore) [137] 2003 • FESS • Workstation; mirrored display, • Endoscope can turn from 0° to 360°
• EETSA stereoscopic glasses, stylus, and control or possible to magnify or reduce the
• Other endoscopic handle (joystick) objects
skull-base surgery • No mannequin head
• Surgical rehearsal
Simulation of Transsphenoidal Endoscopic Pituitary 2004 • EETSA • Integrated into the Impax EE PACS • Collision detection and force
Surgery (STEPS; Medical University Vienna and VRVis • Surgical rehearsal system (Agfa HealthCare, Bonn, feedback
Research Center, Vienna, Austria) [138] Germany) • Can simulate angled endoscopes
• StealthStation image-guided navigation • Preoperative visualization of
system (Medtronic, Minneapolis, MN); important anatomical structures
the endoscope and instruments are
optically tracked
• Control handle (joystick)
CardinalSim (Stanford University, Stanford, CA) [139] 2009 • FESS • Runs on standard PC hardware • Rapid reconstruction of patient-­
• EETSA • Features one haptic device specific endonasal anatomy (1–2 h)
• Other endoscopic • Accepts various commercial haptic • Real-time collision detection,
skull-base surgery devices simulation of tissue deformation, and
• Surgical rehearsal force feedback
VOXEL-MAN SinuSurg (University of Würzburg, 2010 • FESS • Runs on standard PC hardware • Customized algorithms for subvoxel
Würzburg, Germany; Voxel-Man Group, University • Surgical training • Affords a stereoscopic view visualization, volume cutting, and
Medical Center Hamburg-Eppendorf, Hamburg, • Fitted with the Phantom Omni haptic haptic rendering
Germany; Helios Hospital Krefeld, Krefeld, Germany) device (SensAble Technologies, Woburn, • Can accommodate angled
[140] MA) endoscopes
S. Sánchez-Gómez et al.
Flinders Sinus Surgery Simulator 2013 • FESS • Bimanual haptic manipulators: Phantom • Realistic mucosal texture and tissue
(Flinders University, Adelaide, SA) [141] • Surgical training Omni haptic devices (SensAble deformation using voxel- and
Technologies) and Novint Falcon (Novint triangle-based surface mesh models
Technologies, DE) • Collision detection and force
• Runs on a laptop feedback
• No mannequin head • Shading algorithms
• Computer-generated effects of
vasoconstrictive drugs
NeuroTouch Endo (National Research Council of 2013 • EETSA • Bimanual haptic manipulators: Phantom • VR stereovision system; real-time
Canada, Ottawa, ON) [142] • Other endoscopic Omni devices physics-based computation of tissue
skull-base surgery • No mannequin head deformation
• Surgical training • Algorithms managing instrument-­
tissue contacts
McGill Simulator for Endoscopic Sinus Surgery 2014 • FESS • NeuroTouch platform • VR stereovision system; real-time
(National Research Council of Canada) [143] • Surgical training • Bimanual haptic manipulators: Phantom physics-based computation of tissue
Omni devices with customized shafts deformation
• A mannequin's head • Algorithms managing instrument-­
tissue contacts
FESS functional endoscopic sinus surgery, EETSA endoscopic endonasal transsphenoidal approach, PACS picture archiving and communication system, VR virtual reality
From Kim et al. [133]
7  Surgical Planning: Three-Dimensional Imaging, Stereolithography, and Virtual Surgery
107
108 S. Sánchez-Gómez et al.

Fig. 7.8  Preoperative planning of surgery of the nose, sinuses, and 3-dimmensional volume rendering; VC voice command) in operating
skull base with different 2D and 3D models of human head. Source: room, Klapan Medical Group Polyclinic, Zagreb, Croatia, EU (with
LM-VE-3DVR-VC (LM leap motion, VE virtual endoscopy, 3DVR permission) [146]

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ceo.2018.00906.
 Ergonomic Aspects
and Instrumentation in Frontal Sinus 8
Surgery

David Lobo, Jaime Viera-Artiles, Juan Maza,

and Roberto Megía

Table 8.1  General recommendations regarding ergonomics to prevent

8.1 Introduction musculoskeletal disorders
Maintain an appropriate weight and exercise regularly
Endoscopic frontal sinus and skull base procedures are long, Take short breaks throughout your daily activity and take advantage
physically and mentally demanding, and increasingly fre- of these breaks to change posture, do stretching exercises and walk
quent, so it is important to keep in mind ergonomic factors to Organize workspaces (e.g., consulting, emergency, and operating
prevent the development of symptoms and musculoskeletal rooms) according to ergonomic principles
Physical activity prevents the appearance of MSDs, although
disorders (MSDs) [1]. Musculoskeletal symptoms can lead
exercises that strengthen the muscles that are most in demand
to surgical fatigue syndrome, in which the surgeon’s skills, during normal activity are more likely to help
acuity, and overall performance may decline, with detrimen- It is important to consider the particular physical condition of the
tal effects for both the patient and the surgeon. surgeon (previous injuries, affected muscle groups, etc.)
Frontal sinus surgery involves the performance of extremely Take advantage of the knowledge and experience of rehabilitation
physicians and physiotherapists, who can advise on the adoption of
precise and delicate procedures in confined and tight spaces. It
correct postures at work, ergonomics, and exercises suitable for the
often requires maintaining forced and sustained neck, back, workload
and shoulders postures while using endoscopes and manipu-
lating different instruments within such spaces [2]. the back (59.8–71%), neck (46–60.5%), shoulder (45–63%),
Several surveys have been conducted to identify the prev- and wrist (11.7–54%), with approximately one-third of rhi-
alence of musculoskeletal symptoms and any associated risk nologists (23–35%) receiving therapy and 5–7.9% reporting
factors relating to endoscopic sinus surgical technique, in that they have had to limit practice due to work-related mus-
rhinologists in the UK, Europe, USA, and worldwide [3–6]. culoskeletal disorders. For endoscopic sinus surgery, the
These cross-sectional studies, with a response rate reported rates of shoulder symptoms are higher than in other
between 11.2% and 22.2%, have identified musculoskeletal surveys aimed at all ENT surgeon populations [1].
symptoms in 63.5–77% of practicing rhinologists, notably in Although MSDs are highly prevalent among otolaryngol-
ogists, the degree of awareness is rather low and knowledge
of basic ergonomic principles is often insufficient. Hence, an
D. Lobo (*) effort should be made to establish preventive measures and
Department of Otolaryngology, Marqués de Valdecilla University teach ergonomic skills early in training (Table 8.1).
Hospital, Valdecilla Biomedical Research Institute, Santander,
Spain
e-mail: [email protected]
8.2 Surgical Ergonomics
J. Viera-Artiles
Department of Otolaryngology, Marqués de Valdecilla
University Hospital, Research and Innovation Surgery Group- Surgical ergonomics is the methodological study of adapta-
IDIVAL, Santander, Spain tion of conditions of a workplace (in this case, the operating
J. Maza room) to the physical and psychological characteristics of the
Department of Otolaryngology Head and Neck Surgery, Hospital worker (in this case, the surgeon). It is based on knowledge of
Universitario Virgen Macarena, Universidad de Sevilla, anatomy, physiology, psychology, and engineering [7].
Sevilla, Spain
Some key factors are: the design of the surgical instruments,
R. Megía monitor placement, pedals, operating table height, the surgical
Department of Otolaryngology Head and Neck Surgery, Hospital
Universitario Marqués de Valdecilla, Universidad de Cantabria, area to be operated on, or the static nature of the procedure. As
Santander, Spain we will see below, many of these aspects are far from being

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 113
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_8
114 D. Lobo et al.

resolved and there is a vast scope for innovation and the devel-
opment of imaginative solutions to the problems they pose.

8.2.1 Operating Theater Layout

Ramakrishnan et al. reviewed ergonomic recommendations

for endoscopic sinus and skull base surgery based on scien-
tific evidence. These recommendations cover aspects such as
appropriate monitor placement, proper instrument mainte-
nance, adjustable operating tables, correct use of pedals, and
upper body position [8] (Table 8.2).
The optimal height of the operating table is that which
allows the surgeon to adopt a position that is as neutral as
possible, both for the spine and for the arms. The new surgi-
cal tables can be lowered to 66–68 cm from the floor, Fig. 8.1.
More ergonomic designs of the instrumentation table
have been proposed that offer better interaction with the
instruments and scrub nurse, which also improves surgical
time [9].
Various pedals are used to control the irrigation of the
endoscopes, motors, microdebriders, diathermy, etc. The
pedals are often out of the surgeon’s field of vision, who
must locate them by touch while trying to maintain a static
position and adequate control of the instruments and the sur-
gical field. Proper handling of foot-controlled tools is essen-
tial to avoid accidental engagement of the microdebrider,
which may injure operating room personnel [10]. In some
cases, hand switches may mitigate the problem, Fig. 8.2.
Our preferred surgical setup is shown in Figs. 8.3 and 8.4.
The disposition of the surgical team is very important to

Table 8.2  Recommendations for endoscopic sinus and skull base sur-
gery [8]
General Proper instrument maintenance will keep
instruments sharp and lubricated Fig. 8.1  The height of the table is very important in relation to a cer-
Sitting does not appear to confer an overall tain procedure. A lower table requires flexion of the trunk and a higher
advantage, but may limit trunk/lower body strain; table causes strain and fatigue of the upper extremities
needs further study
Eye Appropriate monitor placement: at 80–120 cm
directly in front of surgeon, can shift up to 15° guarantee correct ergonomics and ensure fluid coordination
laterally or down by ≈ 20° during the procedure. As can be seen in Figs. 8.3 and 8.4, the
Limit direct visualization through endoscope lens
Limit time wearing headlight or loupes
scrub nurse stands right in front of the surgeon and the anes-
Upper body Adjust table to keep hand in line with elbow ±10 cm thesia team stands at the feet of the patient.
Keep arms slightly abducted and internally rotated
Limit wrist flexion, deviation, and rotation to <15°
Gently rest shaft of endoscope at superior nasal 8.2.2 Surgeon Position (Standing Vs Sitting)
vestibule when able
Trunk and Take periodic breaks to stretch and restore blood
lower body flow Ergonomic analysis of the surgical position in functional
Do not “hover” over foot pedals endoscopic sinus surgery has been performed on cadaver
Minimize unnecessary use of accessory devices heads [11, 12] and in the operating room [13] and used either
requiring foot pedals
noninvasive surface electromyography [11] or motion analysis
Consider use of hand-operated debrider or cautery
Lean slightly against tablea systems [12, 13]. The sitting position was objectively much
Consider gel mat or ergonomic foot supporta more favorable than the standing position for the left ham-
 For surgeons who stand
a string muscle group but worse for the back and shoulders.
8  Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery 115

Fig. 8.2  The recommendations for endoscopic sinus and skull base surgery cover aspects such as correct use of pedals and correct upper body
position among others

In the standing position, the left arm is exposed to an increased Hand instrumentation, Figs. 8.6, 8.7, 8.8, 8.9, 8.10, 8.11,
risk of musculoskeletal problems due to the lack of support 8.12, 8.13, 8.14, 8.15, 8.16, 8.17, 8.18, 8.19, 8.20, and 8.21.
(which can be counterbalanced by an armrest). If the surgeon A 65° Hosemann Mushroom Punch is useful for clearing
prefers to operate in the seated position, an arm support would osteitic bone from the frontal recess, Fig. 8.6a, b.
also be helpful. Some models of endoscope h­ olders have been Stammberger Punch, circular cutting. Capable of remov-
devised although the most important developments come from ing horizontal partitions in an anterior to posterior direction,
the field of robotics (see below) [14–16] (Fig. 8.5a, b). Fig. 8.7.
Bachert forceps (capable of removing horizontal ledges in
a back-to-front fashion). The Bachert or “cobra” forceps are
8.2.3 Instruments and Equipment employed to clear the agger nasi and frontal recess cells,
Figs. 8.8 and 8.9.
Delicate mucosal-sparing dissection of the frontal recess Through-cutting giraffe forceps. Come in side-to-side and
with the appropriate instrumentation is paramount to mini- front-to-back varieties at both 45° and 90° angles, Figs. 8.10,
mize scar formation and ensure patency [17]. 8.11, 8.12, 8.13, and 8.14.
116 D. Lobo et al.

Fig. 8.3  Appropriate monitor placement at 80–120 cm directly in front of surgeon

Fig. 8.4  View of the operating room setup for endoscopic sinus and skull base surgery
8  Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery 117

a b

Fig. 8.5 (a, b) The endoscope support system is anchored to the operating room table and has an articulated arm that allows it to be adjusted to
the endoscope tubing without obstructing the surgical field. Courtesy of Dr Francisco Valcárcel

a b

Fig. 8.6 (a) Hosemann mushroom punch, (b) close detail

Non-through-cutting frontal giraffe forceps. Come in

side-to-side and front-to-back varieties at both 45° and 90°
angles and different sizes, Figs. 8.15 and 8.16.
Frontal probes and curettes, Fig. 8.17.
Optimal visualization is of utmost importance when per-
forming frontal recess dissection. In general, the minimum
requirement is a 30° endoscope, but a 70° endoscope is pref-
erable for adequate visualization. Reverse or offset angled
endoscopes are extremely helpful because the light-post
does not obstruct access of curved instruments to the frontal
sinus recess, Fig. 8.18.
Fig. 8.7  STAMMBERGER Punch, circular cutting, 65° upturned, WL
17 cm. © KARL STORZ SE & Co. KG, Germany (capable of removing The sinus surgeon holds the endoscope in one hand and
horizontal partitions in an anterior to posterior direction) the surgical instruments in the other and frequently has to
118 D. Lobo et al.

Fig. 8.8  Bachert or “cobra” forceps Fig. 8.12  Same, right-side opening. Kuhn Rhinoforce® II frontal sinus
forceps, flat jaws, through-cutting, straight tip. © KARL STORZ SE &
Co. KG, Germany

Fig. 8.9  Bachert or “cobra” forceps, close detail

Fig. 8.13  Kuhn Rhinoforce frontal sinus forceps Thrucut 90° upturned,
right-side opening, work length: 12 cm. © KARL STORZ SE & Co.
KG, Germany
Fig. 8.10  Kuhn Rhinoforce® II forceps 60° upturned. © KARL
STORZ SE & Co. KG, Germany

Fig. 8.11  Rhinoforce II Kuhn forceps 60° upturned left side. Close Fig. 8.14  Through-cutting giraffe forceps. Side-to-side and front-to-­
detail. © KARL STORZ SE & Co. KG, Germany back 90°. Close detail
8  Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery 119

Fig. 8.18  45° endoscope 4  mm. © KARL STORZ SE & Co. KG,
Germany

Fig. 8.15  Non-through-cutting frontal giraffe forceps. Side-to-side

and front-to-back 90°

Fig. 8.19  Bendable suction instruments with built-in EM surgical

navigation technology

Fig. 8.16  Non-through-cutting frontal giraffe forceps. Side-to-side

and front-to-back 90°. Close detail

Fig. 8.20  90° angle shaver

switch instruments between suction and different types of

forceps. Therefore, malleable suction-dissecting instruments
allow the surgeon to have dissection and suction simultane-
ously and also to customize the tool to the particular anatomy
of the structures involved, Fig. 8.19. Different angle shavers
can also serve this purpose, Fig.  8.20. Bendable suction
instruments with built-in EM surgical navigation technology
are also available.
Powered drills are available in a variety of sizes and
angles. In the author’s opinion the 70° and the 30° diamond
drills are the most useful, Fig. 8.21.
Virtual endoscopy (VE) amplifies the perception of cross-­
sectional images, acquired by axial computed tomography
(CT), in the 3D space, providing precise spatial relationships
Fig. 8.17  Frontal probes and curettes. 90° curved suction of pathological regions and their surrounding structures,
Fig. 8.22.
120 D. Lobo et al.

1884015RTD
1883040BRC
1883040BLC
1884040RTC
1883040BLD
1883655BRC
1883070BLC
1883070BLD
1884070RTC
1884070RTD

Fig. 8.21  Powered drills are available in a variety of sizes and angles

Fig. 8.22  Virtual endoscopy

8  Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery 121

8.2.4 Robotics The maximum forces that could be applied (250 N) were too
high for endonasal surgery and would increase the risk of com-
The main goal of skull base and sinonasal robotics is to plications [20]. To protect the lamina papyracea, one possible
enable three-hand procedures to be performed by one sur- solution was to create kinematic constraints on the robot,
geon alone. It also improves ergonomics. Four-hand surgery thereby preventing the instruments from approaching this area.
allows extensive endoscopic skull base surgery and new Other prototypes present certain disadvantages. For
reconstruction techniques to be carried out by a team of two instance, their structure, workspace design, and high cost
surgeons using several instruments introduced through the make them less suitable for frontal and anterior skull base
two nostrils. The operative time in four-hand surgery is surgery, Table 8.3.
shorter (by an average of 21%) than in two-hand surgery In 2008, Xia et al. created a robot capable of opening the
[18]. However, the four-hand technique is not very ergo- sphenoid by means of a co-manipulation system. With this
nomic and requires two experienced senior surgeons. type of robot, the operator and the robot share control of the
Trevillot et  al. conducted a detailed review of the latest instruments (endoscope, forceps, drill). The robot induces an
advances in robotics in 2013. The first approach to robotics in increasingly strong resistance close to forbidden structures
endoscopic skull base surgery was to adapt the da Vinci® although it has an inaccuracy of about one millimeter due to
robot to this type of intervention. However, the da Vinci® robot an initial placement error, calibration error, or robot kine-
is extremely cumbersome and can only be used in the middle matic error [24] (Table 8.4).
cranial fossa via complex and relatively invasive routes [19]. Several types of interfaces (e.g., voice recognition, head
Several teams of surgical robotic engineers have devel- motion, foot pedal, joystick) can be used to control endo-
oped new robots for endoscopic sinus and skull base surgery scope holders. Another approach is to implement automatic
[20–31]. The main progress has come from the development control of the robot based on visual serving: markers are
of endoscope holders. Although none of the currently avail- attached to the distal part of the instruments and are tracked
able solutions appears to be entirely suitable, the future is by the endoscope so that they remain in the center of the
highly promising. image. However, markers may be temporarily hidden by
blood, smoke, or other instruments, which raises safety con-
8.2.4.1 Endoscope Holders cerns [27]. To overcome this problem, the robot can be
In 2004, Nimski et al. described the first prototype of an endo- equipped with an automatic cleaning system [26, 30, 31]
scope holder used in endonasal surgery (see below (Table 8.3)). (Fig. 8.23).

Table 8.3  Robot endoscope holders

Type of control Workspace
Year Robot name interface Setup time occupied Surgical procedure Clinical trials
Nimski et al. [20] 2004 Evolution 1 Joystick 30 min Major Pituitary No
Nathan et al. [22] 2005 AESOP Voice-controlled 20 min Major Pituitary No

Strauss et al. [23] 2007 None Joystick 20 min Major ASB No

Xia et al. [24] 2008 None Co-manipulation Long Major Pituitary No
Eichhorn et al. [25] 2011 X40 Joystick and Unknown Major ASB No
automatic tracking
Trévillot et al. [27] 2013 HYBRID Co-manipulation Unknown Major ASB No
Kristin et al. [28] 2015 SOLOASSIST Co-manipulation Unknown Medium Frontal skull base No
Friedrich et al. [30] 2017 None Foot pedal and Unknown Medium ASB No
joystick
Zhong et al. [31] 2016- FREEDOM Foot-controlled and 4 min Medium FESS Yes
2020 voice recognition

Table 8.4  Ideal characteristics of a robot to be accepted for frontal sinus and anterior skull base surgery
Safety Force feedback
Decreased surgical time Vision feedback
Easy setup Lens cleaning (as needed)
Enhance the surgeon’s capacities Ergonomy
Adequate working space (interactions with the environment) Speed of the learning curve
Accurate and careful tissue handling (interactions between the Robot dimensions (as small as possible)
instruments held by the robot and the tissues) Friendly human–machine interface
122 D. Lobo et al.

The surgeon frequently moves the endoscope in and out moves the endoscope as in conventional surgery, and the
of the nostril. Thus, in co-manipulation mode or robot-­ robot follows the motion of the endoscope and maintains it in
assisted endoscope manipulation, the surgeon manually position when the surgeon no longer holds it. This allows the
surgeon to leave the endoscope in a stable position, freeing
one hand when necessary [26]. Robotic-assisted scope hold-
ing eliminates tremor of the human hand and fatigue, espe-
cially during prolonged skull base resections [31]. Safety is
an important concern since the co-manipulation system does
not provide haptic feedback of the forces exerted by the
endoscope on the nasal cavity, thus increasing the risks of
tissue damage [27].
Most systems have not been evaluated at the clinical stage.
The foot-controlled robot-enabled endoscope manipulator
(FREEDOM) is a new compliant endoscope holder that has
been used in various FESS procedures, Fig. 8.24. It does not
require a separate hand to manipulate the joystick [31]. Even
so, the surgeon is still required to perceive a lens–tissue colli-
sion in order to take immediate action. Sensor-based measure-
ments could make it possible to automatically avoid such
situations.
Despite the benefits they can provide, scope-holding
devices have not gained popularity because of the constant
Fig. 8.23  Prototype of a robot guided endoscopic support system [26] need to change the position of the endoscope to view the dif-

Fig. 8.24  Active part of the

robotic arm in detail [32]
Handle

arc rack

Linear joint

Endoscope

Inserting joint
Rotary joint

Human head model

8  Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery 123

Table 8.5  Proposed checklist for frontal sinus surgery

Proper imaging display
Discuss anatomic variations (see Chaps. 3, 6, and 7)
Discuss topical or injectable anesthetic/vasoconstrictor with anesthesia
Labeled topical and injectable anesthetic/vasoconstrictor
Statement of specimen collection
Suction monopolar cautery
Confirmation of pledget count

effort, interaction with computers, human reliability, safety

actions, and work stress.
It is extremely important to implement measures to reduce
stress and cognitive load [33]. Significant reported stressors
for trainee surgeons include the use of angle endoscopes
(they must be used as often as possible to attain proficiency),
other colleagues or students entering the theater, poor vision
due to bleeding (see below), and preoperative waiting due to
the permanent time pressure in the hospital. The same situa-
tion is likely to exist for supervisors in frontal sinus surgery.
Fig. 8.25  Robotic Endoscope Guidance System. The robotic guidance Surgical training should take place in a familiar environ-
system consists of an intelligent mechatronic holding arm with four ment, and without time pressure [34, 35].
segments and seven degrees of freedom. A robotic hand with five active
degrees of freedom is attached to the tip, realizing movement of the
endoscope [30]
8.3.1 Surgical Safety Checklist

ferent areas of the required surgical field. Moreover, despite The overall goal of a checklist is to improve the safety of
the relative accuracy of some of these systems, a minute surgical procedures, reduce errors, and minimize avoidable
error in the skull base could result in life-threatening or even complications. Surgical errors during frontal sinus surgery
fatal damage, Figs. 8.24 and 8.25. may lead to major complications such as orbital and skull
base injury. This is reflected in US malpractice litigation
where rhinology claims represent 70% of the total indemnity
8.2.5 Additional Considerations compensation for otolaryngology lawsuits. Sinus surgery is
the surgical procedure most often involved and sinusitis is
Surgeons tend to maintain a fairly static position in moments the most common diagnosis [36, 37]. The use of an endo-
of maximum concentration. This can lead to muscle fatigue scopic sinus surgery checklist improves the chances that
and contribute to the development of MSDs. It is advisable to individual safety tasks are performed during the course of
take small breaks or do stretching exercises from time to sinus surgery [38]. The checklist may be of particular value
time to relieve such stress or fatigue, as well as performing when frontal sinus surgery is performed in emergency situa-
changes in posture during surgical procedures. The use of tions or in less familiar environments. Specialized equip-
surgical mats, footrests, or other support systems for sur- ment and medications may be incorporated in the checklist if
geons has been shown to reduce muscle fatigue associated they are critical aspects of the surgical approach [39]
with postural control [8]. (Table 8.5).
As reported by Soler et al., the least commonly performed
task was discussing the use of a topical vasoconstrictor with
8.3 Cognitive Ergonomics the anesthesiologist (Table 8.6).

While physical ergonomics focuses on injury prevention

through design and evaluation of workplaces, instruments, 8.3.2 Surgical Field
and equipment, and intervenes on the surgeon's postures,
repetitive movements, etc., cognitive ergonomics is con- It is of great importance to achieve good hemostatic control
cerned with surgeon’s performance in terms of quality. The of the surgical field. Preoperative considerations include
most important aspects include decision making, mental management of comorbidities (e.g., hypertension, coagulop-
124 D. Lobo et al.

Table 8.6  Proposed checklist for frontal sinus surgery (Fig. 1 in [38])
Step 1: Preparation (surgeon only)             Timing: prior to intubation
1. Lead surgeon reviews (assisting surgeon(s) confirm)
 a. Correct CT/MRI displayed in room (patient, date, sideness)
 b. Image guidance in room, proper scan uploaded, correct views available (if necessary for case)
 c. Important anatomic variations identified and discussed among surgical team (skull base erosion, dehiscent lamina papyracea,
Onodi cell, etc)
Step 2: Pause/time-out (full operative team)        Timing: prior to instrumentation
2. Review/confirm roles vary by institution
 a. Complete standardized surgical checklist
   • WHO-equivalent (site, procedure, antibiotics, etc)
   • Exact organization expected to vary by institution
3. Surgeon reviews (anesthesia, nursing and tech teams confirm)
 a. Topical epinephrine/cocaine/oxymetazoline stained and labeled appropriately
 b. Injectable anesthetic labeled and left unstained
 c. Suction cautery/bipolar immediately available in room
 d. Method of specimen collection (sideness, microdebrider trap, fresh/formalin)
Step 3: Completion (surgeon, nursing, tech)        Timing: prior to extubation
4. Surgeon reviews (nursing and tech teams confirm)
 a. Pledget count correct
 b. Documentation of materials left in situ (stents, spacers, packing)
 c. Specimen property collected, labelled, and sent to pathology

athies), medication management, and systemic versus topi-

cal corticosteroids. Intraoperatively, local injections with
adrenaline and lidocaine and topical application of cocaine/
adrenaline improve the surgical field. As already described
by Wormald et  al., remifentanil/propofol total intravenous
anesthesia and maintaining a mean arterial pressure of
around 65 mmHg and pulse rates of 60 or less result in less
bleeding and improve the surgical field. Access septoplasty
(even if it only partially blocks the axilla of the middle turbi-
nate) creates more room and makes surgery easier [35]. Hot
saline irrigation may be beneficial in improving the surgical
field in functional endoscopic sinus surgery after 2 h of oper-
ating time. The rate of blood loss can be significantly reduced
with hot saline irrigations [39].
Ultra-high definition (UHD) 4k systems, first released in
2015, provide a detailed view of all anatomical structures
and pathologies, which can result in improved safety and
efficacy of the surgical procedure. It is fundamental to set the
chromatic configuration, especially with red wavelengths, in
order to achieve good color perception during bleeding in
surgical procedures [40].
Endoscopic irrigation systems, such as the Endo-Scrub
(Medtronic ENT Medtronic USA, Inc, Jacksonville, FL)
have been shown to improve operative visibility in the pres-
ence of bleeding without the need to remove the endoscope
from the nares for manual cleaning.

8.3.3 Image-Guided Navigation System Fig. 8.26  StealthStation ENT navigation system

While a surgery checklist and 3D image guidance increase

confidence, the true role of image guidance lies in confirm- Based on the author’s own experience the navigation sys-
ing the anatomy that the surgeon has already carefully exam- tem should be used as often as possible to become acquainted
ined, Fig. 8.26. with it. Otherwise, these systems lead to more stress than
8  Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery 125

real help for the surgeon. With regular use and not just in
selected cases, the preparation of the navigation system takes
just a few minutes and can be done while preparing the
patient on the operating table. In this way, not only does it
not take more time, but the use of navigation can result in a
saving of up to 10% of OR time [41].
Navigation is most often used to find the frontal sinus, the
most demanding part of a FESS, even for experienced sinus
surgeons [42]. Experienced surgeons report better intraopera-
tive orientation, improved situational awareness, and lower
surgical risk with the use of the navigation system [43].
Navigation has a place in training and teaching frontal
sinus surgery (see Chaps. 2 and 7). For the trainee surgeon,
particular steps of the operations are carried out more reli-
ably and safely. The additional information provided by
image-guided navigation also helps the trainee to develop a
better anatomical understanding. In the group of somewhat
experienced operating surgeons (>30 paranasal sinus opera-
tions), the assistance system is particularly effective [34].
However, the navigation device cannot replace a human
supervisor. Experienced FESS surgeons only trust the system Fig. 8.27  Manual contouring of preoperative CT scans
with increased frequency of use, whereas beginner surgeons
tend to overestimate the possibilities of the system and to tem could reduce task workload during frontal sinus surgery
underestimate the risks [42]. It is not advisable to operate and and potentially increase safety and efficiency. Providing live
consult the navigation system only in critical situations without navigational data may reduce the cognitive demand required
having established a detailed preoperative plan. As we stressed for orientation. In augmented, real-time image-­guided surgery,
earlier, a preoperative checklist and precise plan for intraopera- pertinent anatomy and surrounding alert zones (critical struc-
tive dissection based on the CT findings are essential. tures, e.g., dura, orbit, lying behind the visible surface) are
Navigation systems are assistance systems displaying precontoured on the CT scan and then displayed in the virtual
positional data in relation to the preoperatively prepared CT endoscope image. Ablative instruments are tracked and the
or MRI. Computer-assisted surgery (CAS) helps the surgeon system provides proximity feedback and alerts [47].
locate or avoid anatomically important regions. Different In addition, virtual reality may have a role to play in surgi-
applications in frontal sinus surgery are being explored such cal training. Manual contouring of preoperative CT scans is
as control systems of power tools (drills, cutters, shavers, labor intensive but this task may provide the surgical trainee
high frequency scalpels, etc.) or endoscope holders. For with a greater understanding of the anatomical relationships
instance, the on/off status of the shaver is regulated automati- and boundaries of the operative field [48], Fig. 8.27. Semi-­
cally, depending on the position of the shaver tip. Prior deter- automatic segmentation of anatomical structures can help in
mination of the working space is required, which is this task in case of insufficient time.
time-consuming. This information can be held in the back- At present, this system does not provide truly real-time
ground so that it is present only when the resection limits are image guidance, as it still has to account for tissue deforma-
exceeded in which case it complements the visual informa- tion and ablation in the virtual view.
tion on the endoscope monitor and navigation screen [44]. Finally, in a randomized controlled study, there was no
clear performance gain in terms of efficiency or accuracy
[47]. No technology is substitute for experience. Real-time
8.3.4 Augmented Real-Time Image Guidance navigation may, in fact, lead to distraction rather than safer
surgery [49], although the true value of this technology in
The navigation monitor is usually in a different line of sight frontal sinus surgery has yet to be clarified.
from that of the video endoscope monitor [44, 45]. In a typi-
cal procedure the surgeon moves the eyes from the endo-
scope monitor to the navigation display, then continues with 8.3.5 Additional Considerations
the dissection. New navigation systems allow the display of
navigation and endoscope images on the same screen. Most of the surgeons questioned in a survey reported not
Augmented reality navigation systems fuse endoscopic feeling sufficiently well trained to handle the electromedical
images to a 3D reconstructed background, providing a stereo- equipment. This, of course, can be a source of stress and
scopic view that is displayed on a single screen [46]. This sys- frustration [10].
126 D. Lobo et al.

It is also fundamental to enjoy a good work environment. 15. Raman R, Prepageran N.  Novel use of a Leyla-Yasargil retractor
as an endoscope holder during endoscopic sinus surgery. Ear Nose
In order to achieve his goal, teams should be as stable as
Throat J. 2004;83(4):270.
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and consistently rather than sporadically with the consequent tive endoscope holder system for endoscopic otolaryngological sur-
risk of inadequate performance. geries. Indian J Otolaryngol Head Neck Surg. 2015;67(2):113–9.
https://doi.org/10.1007/s12070-­014-­0738-­y.
The ideal would be to establish a proactive, dedicated
17. Tajudeen BA, Adappa ND.  Instrumentation in frontal sinus sur-
team, identified with the institution. This would serve to gery. Otolaryngol Clin N Am. 2016;49(4):945–9. https://doi.
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quality of patient care, and a vocation for constant 18. Briner HR, Simmen D, Jones N.  Endoscopic sinus surgery:

advantages of the bimanual technique. Am J Rhinol. 2005;19(3):
improvement.
269–73.
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not lie solely in improving techniques or design, but also in L.  Robotic endoscopic sinus and skull base surgery: review of
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training.
anorl.2012.03.010.
20. Nimsky C, Rachinger J, Iro H, Fahlbusch R.  Adaptation of a

hexapod-based robotic system for extended endoscope-assisted
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 Part II
Step by Step Procedures
 Frontal Balloon Sinuplasty: Frontal
Sinus Surgery Without Tissue Removal 9
Guillermo Plaza, Peter Baptista, and Elgan Davies

9.1 Introduction The concept of dilating an ostium via a high-pressure bal-

loon was initially developed and promoted in the field of car-
Chronic rhinosinusitis (CRS) affects approximately 10–15% diology. The introduction of high-pressure balloon dilation
of the adult population [1]. Obstruction of the sinus ostia is catheter technology in 2005 to create sinus ostia enlargement
one of the main mechanisms that contribute to the develop- led to the development of the “balloon sinuplasty” procedure
ment and maintenance of CRS by impairing ventilation and [6, 7]. Several studies support the concept that balloon sinu-
drainage of the sinus cavities [2]. In patients with CRS, the plasty to open and remodel sinus ostia is an effective treat-
frontal sinus is frequently affected. It may significantly con- ment of CRS with consistent long-term results [8–11].
tribute to the impact of the disease on quality of life, making it Technological innovation, improvements in balloon
a high priority target for medical and surgical intervention [3]. catheter-­assisted dilatation techniques, and higher experi-
Treatment of CRS involves medical treatment, surgical ence with this procedure now facilitate the use of balloon
treatment, or a combination of both. Surgical therapy should catheters under local anesthesia in the office [12–15]. Thus,
only be offered after a failed course of intensive medical balloon sinuplasty refers to solely dilating the maxillary,
treatment [2]. The most frequently used surgical approach frontal, and sphenoid sinuses' natural drainage pathways
is functional endoscopic sinus surgery (FESS), designed to without removing any tissue. Because of its mucosal-sparing
establish patency of the sinus drainage pathways and enhance nature, it typically results in less bleeding and more rapid
mucosal clearance [2]. healing, requires fewer postoperative debridements, and may
Although shown to be very effective, FESS typically allow for earlier return to work [5, 16, 17].
requires general anesthesia and carries the risk of scarring These advantages make balloon sinuplasty ideal for fron-
and adhesions within the ostiomeatal anatomy [4]. The word tal sinus disease [5, 18]. Luong et  al. [19], Catalano et  al.
“functional” emphasizes the preservation of normal mucosal [20], and Hopkins [21] were the first to report frontal bal-
clearance via the natural anatomic drainage pathways. This loon sinuplasty as a stand-alone procedure. However, other
is of utmost importance in the frontal recess. Here, mucosa authors reported failures and complications related to this
preservation is paramount to prevent restenosis (recurrence procedure [22, 23].
of narrowing) and consequent complex and potentially haz- The aim of this work is to review indications, advantages,
ardous revision procedures [5]. tips, and pitfalls of frontal balloon sinuplasty that may help
to select the ideal candidate to this technique.

Supplementary Information The online version contains supplementary

material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_9].
9.2 Indications
G. Plaza (*)
Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
Before considering for surgery, patients with CRS should
have failed appropriate medical therapy, have persistent
Associate Professor of Otolaryngology, Universidad Rey
Juan Carlos, Madrid, Spain
symptoms of at least 12 weeks, and demonstrate evidence of
e-mail: [email protected] CRS on computed tomography (CT) [2, 5, 17].
P. Baptista
In frontal balloon sinuplasty, patient selection is of par-
Clínica Universitaria de Navarra, Pamplona, Spain amount importance, being CRS without nasal polyposis
E. Davies
(CRSsNP) the ideal candidate [5, 17]. Therefore, a careful
Spire Regency Hospital, Macclesfield, UK review of CT images is mandatory to identify any potential

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 131
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_9
132 G. Plaza et al.

anatomic variations such as middle turbinate concha bullosa, (Irvine, CA), Entellus Stryker (Plymouth, MN), Medtronic
paradoxical curvature of the middle turbinate, and nasal sep- (Minneapolis, MN), and Smith & Nephew (Cordova, TN).
tal deviation that would make sinus access difficult [5, 17]. All but Acclarent are available in Europe at this moment.
Frontal sinus disease management remains one of the In the case of Acclarent there is a need for a catheter, a
most challenging undertakings in FESS.  Anatomic studies lighted guidewire, and the balloon. To enter the frontal sinus
have demonstrated that the underlying problem in chronic you may choose a 70° or 90° catheter. It is endoscopically
frontal sinusitis is not the sinus but its drainage pathway positioned at the entrance of the frontal recess. The guide-
through the frontal recess. The frontal recess is an inverted wire is passed through the catheter into the sinus, and the
funnel-like area that connects the frontal ostium superiorly balloon advanced over it, positioned to straddle the ostium. It
to the anterior ethmoidal space inferiorly. It is usually pneu- is then transiently inflated to high pressure (up to 8–12 atmo-
matized by various frontal recess cells, which may cause spheres), thereby pushing the bony partitions obstructing the
­anatomical frontal recess obstruction and be the primary recess out of the way.
cause of chronic frontal sinusitis [24, 25]. The complex On the contrary, the Entellus balloon (XprESS®) is incased
anatomy and its anterosuperior location render endoscopic in one device. This means that there is no need for separate
frontal recess dissection and visualization difficult, therefore instruments. The guide, the LED light, and the balloon are
predisposing it to surgical failure. in one set and, by bending the guide according to the needed
The critical goal of operating on the frontal recess is to angle, there is the possibility to enter any of the ostium of the
relieve obstruction of the outflow tract and treat the existing frontal, maxillary, or sphenoid sinus.
disease from an anatomical perspective and more importantly, Medtronic has a series of different navigated balloons that
prevent recurrence of disease. This goal is inherently easier are connected to the navigation system. There is a need to
to achieve in primary surgical intervention. Unfortunately, choose the adequate balloon according to the sinus that will
iatrogenic causes have a significant role in recurrent fron- be dilated.
tal sinusitis, with neo-osteogenesis and recurrent polyposis Both Entellus and Medtronic devices are specifically
being significant factors [2, 5]. designed for some of the unique frontal sinus outflow tract
Within the frontal sinus outflow tract, balloon sinuplasty anatomy features, mimicking a frontal sinus seeker. They
allows for greenstick fracturing and lateral displacement also offer different abilities to change the trajectory of the
of the medial and superior wall of obstructing frontal cells, tip of the wire, which improves proper ostial cannulation,
medial displacement of an obstructing intersinus septal cell subsequent balloon advancement, and dilation of the frontal
wall, and/or dilating soft tissue stenosis in previously operated sinus outflow tract.
patients [5–7, 17]. Therefore, rather than excising inflamed In some cases, the balloon device may be used as a tool
tissue and the adjacent bone, in theory, the balloon com- to enter and dilate the ostium of the frontal sinus without the
presses the mucosa and causes microfractures of the under- need to touch the anterior ethmoid cells (stand-alone balloon
lying obstructive bony wall, thereby creating ostial patency. dilatation). In other cases, as mentioned, there is the possibil-
However, ostial patency alone may not be enough to ity of performing an anterior ethmoidectomy with standard
assure an ideal outcome. Thus, balloon sinuplasty should FESS instruments or microdebrider and then dilating the
not be performed if there is suspicion or pathologic con- frontal recess using the balloon device (hybrid technique).
firmation of neoplastic disease [5, 17, 23]. In patients In these cases, there is a better endoscopic visualization to
with CRS with nasal polyposis (CRSwNP), balloon sinu- access the frontal recess.
plasty alone may also not be sufficient. In such cases, tis- Image guidance system (IGS) can be used concurrently to
sue removal and surgical widening of the outflow tract by confirm correct positioning in the frontal sinus.
removing frontal recess cells are necessary to address dis- Frontal balloon sinuplasty can be performed in the oper-
ease and facilitate local drug delivery. In these situations, ating room (OR) under general anesthesia or under local
it may be used in conjunction with traditional FESS tech- anesthesia. This can be done in the OR setting or in the in
niques (“hybrid technique”) to conduct frontal sinus sur- office, with the patient either sitting in a 90° or 30–45° posi-
gery [26, 27]. tion. However, diligent patient counseling and preparation
are critical for achieving success within the office setting for
frontal sinus procedures. We believe that they should not be
9.3 Schematic Description offered to every patient.
These procedures performed in the office setting have
Several commercial devices are currently available for important advantages of eliminating the risks and recovery
frontal balloon sinuplasty. Currently, there are four manu- of general anesthesia and avoiding the associated costs with
facturers of balloon sinuplasty devices approved by the US the hospital outpatient department or ambulatory surgical
Food and Drug Administration (FDA), namely Acclarent facility [28, 29] (Fig. 9.1).
9  Frontal Balloon Sinuplasty: Frontal Sinus Surgery Without Tissue Removal 133

Fig. 9.1  Frontal balloon sinuplasty schema: step 1: insertion of guidewire. Step 2: insertion of balloon. Step 3: dilation of balloon

9.4 Pearls and Potential Pitfalls • It is a simple and fast tool, but a very expensive too; there-
fore, indications must follow strict rules.
Frontal balloon sinuplasty offers some pearls to the • It does not allow to obtain biopsies.
rhinologist:

• It can be performed safely in the office, even in revision 9.5 Surgical Procedure Step by Step
cases.
• It can be used as a simple through transillumination even The patient is prepared by application of topical 4% lido-
when IGS is not available (to find the frontal sinus). caine combined with topical oxymetazoline cotton pledgets.
• It reduces mucosal trauma, avoiding scarring more com- They should be placed medial and lateral to the middle tur-
monly related to drilling during Draf procedures. binate to allow for gentle medial displacement of the middle
• It avoids osteitis and new bone formation. turbinate once anesthesia is achieved.
A 0° or 30° endoscope is typically used at the beginning
However, frontal balloon sinuplasty has also several to allow for a broad field of visualization. Access to the fron-
pitfalls: tal sinus is best achieved if the tip of the 70° sinus guide
is placed between the uncinate process and the face of the
• It should not be used to localize the frontal recess in unex- ethmoid bulla in the parasagittal plane.
perienced hands. The distal tip should be visible near the upper third of the
• Any ENT may perform it, but this surgeon should be able ethmoid bulla and not passed into the frontal recess to allow
to convert to more complex surgery at the same time or the guidewire to explore a broader area in search of the path-
later date, and as such, should be informed to every patient. way into the frontal sinus.
134 G. Plaza et al.

At this point, the guidewire is advanced into the frontal a

sinus. If the guidewire does not easily pass into the frontal
sinus, retracted back into the sinus guide, the sinus guide
is repositioned, and attempted cannulation is repeated. Once
proper placement of the device is confirmed, an appropri-
ately sized balloon (diameter and length are considerations)
is advanced and dilated to 10–12 atmospheres of pressure.
Once the frontal sinus is successfully accessed, balloon
advancement and dilatation are performed. They may be
repeated more proximally or distally within the frontal sinus
outflow tract depending on the frontal anatomy and length of
the balloon chosen. This is in the case of Acclarent device.
As mentioned before, with the Entellus device, LED
light source and balloon are encased in one instrument.
The semirigid shaft that is malleable comes in 70° angle
and is placed through endoscopic vision towards the fron- b
tal recess area, avoiding excessive pressure but assur-
ing passage of the LED light and confirming by bright
transillumination that it is in the frontal sinus. The bal-
loon is passed slowly and consistently towards the area
to be dilated. Balloon dilation is reached through a spe-
cial syringe that was previously adapted to the device
(Figs. 9.2, 9.3, 9.4, and 9.5).
With the Medtronic device, there is the possibility of hav-
Fig. 9.3 (a) Balloon acclarent LUMA.  The guide, the light, and the
ing navigated balloons that work with the IGS, where the balloon are to be connected during the procedure to the inflation device.
distal tip of the balloon is linked to the navigation system to (b) Balloon acclarent relieva. The guide, the light, and the balloon are
provide adequate placement. connected in one only device

Fig. 9.2 (a) Balloon Entellus a

XprESS: The guide, the LED
light, and the balloon are in
one set and. (b) The inflation
device connected at the back
of the set

b
9  Frontal Balloon Sinuplasty: Frontal Sinus Surgery Without Tissue Removal 135

a b

Fig. 9.4 (a) Frontal balloon sinuplasty Acclarent insertion, holding both endoscope and balloon with one hand. (b) Detail

At the end of the procedure, irrigations can be performed,

allowing the instillation of antibiotics or other drugs within
the frontal sinus.

9.6 Postoperative Tips

As in any other frontal sinus procedure, complications may

happen. Bleeding during the procedure may hazard it, and
the surgeon must be prepared to avoid mucosa damaging
while dealing with it.
Chaaban et al. [30] compared the rates of complications
and revision surgery in patients who received balloon sinu-
plasty, conventional FESS, or a hybrid procedure, includ-
ing a total of 16,040 patients. The complication rate was
5.26% for balloon sinuplasty and 7.35% for conventional
FESS.  Revision rates were 7.89% for balloon sinuplasty,
16.85% for FESS, and 15.15% for a hybrid procedure.
As a major complication, cerebrospinal fluid (CSF) leak
has been reported, more related to ethmoid work as prepa-
ration to frontal recess during hybrid procedures. In 2016,
Prince and Bhattacharyya reviewed adverse events reported
using balloons in sinuses on the open FDA database [31].
Of the 114 reported adverse events, there were 15 CSF leaks
(frontal and sphenoid). More recently, Hur et al. [32] have
reported adverse events from MAUDE (Manufacturer and
User Facility Device Experience) during ten years (2008–
Fig. 9.5  Frontal balloon sinuplasty transillumination
2018). Of the 211 reported adverse events, the most common
136 G. Plaza et al.

patient-related complications were CSF (36.3%), eye swell- As a useful tool in revision frontal surgery, several stud-
ing (29.4%), and epistaxis (11.8%). ies have retrospectively examined patients undergoing
Scarring and recurrence of frontal sinusitis do happen, office-­based revision frontal sinus balloon dilation [46–51].
with a published success rate after primary surgery of around Bhandarkar et  al. [49] first reported a case where balloon
80% after 24 months of follow-up. Several studies and meta-­ sinuplasty was used with IGS and followed by drilling of
analyses have reported significant reduction in sinonasal the frontal sinus outflow tract. Eloy et al. [50] reported ret-
symptoms and healthcare use after balloon sinuplasty, very rospectively on five patients who had office-based dilation
low rate of revision surgery, and efficacy similar to FESS in of a stenosing frontal neo-ostium using transnasal balloon
CRS treatment, including the frontal sinus [33–39]. dilation instrumentation. All five patients were asymptom-
As primary surgical treatment of frontal sinusitis, early atic at a mean follow-up of 5 months with patent drainage
results come from 2009. Catalano et al. [20] examined the pathway. Luong et  al. [19] studied six patients undergoing
use of frontal balloon sinuplasty to treat CRS in 20 patients office-­based dilation for postoperative frontal sinus ostium
with advanced frontal sinus disease that had failed medical stenosis. They found that durable patency was achieved in
therapy. They found that pretreatment and posttreatment all six frontal sinuses dilated, with only one patient requiring
Lund-Mackay scores showed significant improvement in a ­second dilation due to ostium contraction >50% during the
patients with certain subsets of chronic rhinosinusitis, par- follow-­up range of 4–9 months. Jang et  al. [51] have ana-
ticularly those patients with chronic rhinosinusitis without lyzed data from MarketScan (Truven Health) over a 5-year
nasal polyposis. Hopkins et al. [21] reported an acute frontal period (2012–2016) including 62,304 patients. After two
sinusitis case that was cured after balloon sinuplasty. years of follow-up, 6847 (10.99%) underwent revision sur-
Several studies have examined frontal sinus patency gery, being again a balloon dilation in 20–40% of cases.
rates post-FESS.  Chan et  al. [39] examined 294 frontal Frontal balloon sinuplasty can also be used in conjunction
sinuses operated using traditional FESS techniques. Long- with traditional FESS techniques as a hybrid procedure. After
term patency was achieved in 88%. Naidoo et  al. [40] the initial multicentric reports [8–11], several randomized
reported on endoscopic modified Lothrop (Draf III) with an controlled trials (RCT) have been published. Plaza et al. [52]
average length of follow-up of 45 months. It was successful published a double-blind RCT comparing frontal balloon
in 95% (217/229), with no further surgery being required. sinuplasty (Acclarent device) to conventional frontal sinus
Similarly, Ting et  al. [41] examined 204 frontal sinuses drainage with a Draf I procedure, performing each technique
operated using frontal drillout surgery with a mean follow- in one frontal sinus or the other, as part of a hybrid surgery.
up of 10 years. Symptomatic re-obstruction of the frontal Thirty-two patients concluded the trial. After 12 months, in
sinus requiring revision surgery occurred in 61 (29.9%) both groups, they obtained a statistically significant reduc-
patients. After frontal balloon sinuplasty, few studies have tion in the Lund-Mackay stage. Resolution of frontal sinus
been published with long-term follow-up. Karanfilov disease confirmed by CT and endoscopic permeability of
et al. [13], including in-­office surgeries, reported that 251 the frontal recess were more frequent after balloon treatment
of 268 frontal sinuses were successfully dilated (93.7%), (73% versus 62.5%). Only four patients needed revision
with only five frontal sinuses requiring revision procedures surgery. No major complications were observed. Hathorn
(2%) after 24 months of follow-­up. Szczygielski et al. [42] et  al. [53] performed a single blinded, randomized, con-
reported imaging findings in the frontal sinus drainage trolled, prospective study of 30 patients undergoing FESS
pathway after balloon sinuplasty, observing a significantly for CRS.  Similarly, patients underwent a hybrid approach
average increase of 24% of size in CT in 23 patients having with balloon dilatation (Ventera device) on one side and tra-
postop CT after 6 months of surgery. Yang et al. [43] have ditional frontal sinusotomy for the opposite side. The results
reported on 1489 balloon sinuplasties in China, including demonstrated reduced blood loss and operative time in the
59 stand-alone frontal sinus cases, finding a frontal sinus hybrid balloon technique, with comparable patency to tra-
opening rate of 96.61%, and clinical improvement in 57 of ditional frontal sinusotomy at 1 year postoperatively. None
the cases. required revision frontal surgery. Minni et al. [54] presented
A controversial indication of frontal balloon sinuplasty is a multicentric retrospective randomized study including 76
recurrent sinus barotrauma. Using this tool to manage iso- frontal sinuses with non-polypoid CRS. Of those, 41 frontal
lated frontal outflow tract stenosis as a discreet lesion caus- sinuses were treated with balloon sinuplasty alone and 35
ing frontal recurrent sinus barotrauma is a direct approach to frontal sinuses with both sinuplasty (Acclarent device) and a
solve this disease. Those patients suffering from aerosinus- non-absorbable stent (Relieva Stratus™ MicroFlow spacer).
itis are potentially helped by this surgery. However, several Their results confirm a good safety and effectiveness of bal-
authors have reported failures or relapses. Further research loon sinuplasty in the management of frontal CRS and show
must be performed to compare long-term outcomes of this a good safety but a not significative effectiveness of stenting
technique to the standard of care [44, 45]. when added.
9  Frontal Balloon Sinuplasty: Frontal Sinus Surgery Without Tissue Removal 137

Table 9.1  Published results after balloon frontal sinuplasty (only papers reporting results on frontal sinus are included)
Year N F-UP Fro Frodil (%) End (%) CT (%)
Bolger et al. [8] 2007 115 6 124 97 82 –
Kuhn et al. [10] 2008 46 12 74 – 85 92
Catalano and Payne 2009 20 6 31 94 – 48
[20]
Garvey [62] 2009 45 6 72 97 –
Friedman et al. [63, 2009 120 – 101 81 – –
64]
Kutluhan et al. [65] 2009 30 12 49 96 – –
Wycherly et al. [66] 2010 13 7 24 – 86 a

Hopkins et al. [67] 2010 27 2 41 97 – –

Plaza et al. [52] b 2011 16 12 26 80 75 81a
Albritton et al. [12] c 2012 37 12 21 100 – –
Karanfilov et al. [13] c 2013 203 6 268 93.7 98 –
Gould et al. [15] c 2014 82 12 54 100 80 –
Hathorn et al. [53] b 2015 30 3 30 100 100 –
Szczygielski et al. 2017 24 6 23 – – 24.1 increased
[47]
Minni et al. [54] 2018 76 12 24e 100 91.7 1.76 to 0.53a
17f 100 88 3.42 to 0.67a
Yang et al. [48] 2020 1125 6 59 96.61 – –
N number of treated patients, F-UP minimum follow-up (months), Fro number of frontal sinuses, Frodil percentage of successfully dilated frontal
recesses, End percentage of endoscopic permeability of the frontal recess, CT percentage of CT resolution of frontal sinus opacification
a
Significant reduction in frontal Lund-Mackay scale
b
Randomized control trial: only the group randomized to sinuplasty is included
c
In-office frontal sinuplasty
d
Frontal sinus drainage pathway increasing in 3D-size after treatment
e
Mild frontal sinusitis
f
Severe frontal sinusitis

Despite these reports showing excellent results after frontal Published results after balloon frontal sinuplasty are
balloon sinuplasty including retrospective series [19, 20, 33], shown in Table 9.1.
prospective studies [8–11, 13–15, 36], RCT [34, 35, 52–54], and
meta-analysis [39–41], several authors have strongly criticized
this tool, and a large number of rhinologists do not perform nor 9.7 Summary/Conclusion
recommend it [55–57]. Reasons for this critique may arise from
their failure while performing the dilatation, but also from a Balloon catheter-assisted dilatation is an important tool avail-
conventional point of view refractory to the introduction of this able for addressing frontal sinus disease. Before undertaking
tool. As defined by AAOHNS consensus, “balloon sinuplasty is frontal balloon sinuplasty, it is important to understand the
appropriate for certain indications, and the evidence supports its significance of carefully selecting the appropriate procedure
effectiveness in limited and well-defined circumstances” [58]. for the unique clinical situation with the assessment of the
However, recently other authors have been able to repro- underlying disease process, patient anatomy, and technique.
duce good results after balloon sinuplasty, showing it is an Frontal balloon sinuplasty may serve as a stand-­alone or
effective tool when appropriately selected. Hanci et al. [59] complementary procedure for treating medically refractory
showed better olfaction results after balloon sinuplasty than chronic rhinosinusitis.
after conventional FESS.  López et  al. [60] have elegantly
shown in fresh cadaver heads how endoscopic balloon dila-
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 Cells Removal: Draf Type I and IIA
10
Jaime Viera-Artiles, Roberto Megía, and David Lobo

10.1 Introduction is comfortable operating with angled scopes, the possibility

of visualizing correctly all the anatomical landmarks and the
The frontal sinus is probably the most challenging area of the tip of the instruments during the whole process will make the
nasal cavity to operate on, in the context of an FESS. This is surgery easier and safer.
mostly due to its distribution in the coronal plane rather than The frontal sinusotomy Draf IIA requires the removal of
in the sagittal plane (like the ethmoids and the sphenoids). the cells in the frontal recess from the orbital wall to the mid-
Consequently, the frontal sinus often requires the use of dle turbinate. Dominating this procedure is a key milestone
angled instruments and scopes. Furthermore, the variability in the learning process of a rhinologist. This step is crucial to
of the cells forming the frontal recess, which determines the advance into more complex procedures like Draf IIB, Draf
frontal sinus draining pathway makes its visualization diffi- III, and endoscopic craniofacial resections, thus, the impor-
cult [1]. Moreover, the sub-optimal results in patients with a tance of understanding the anatomy and mastering this
narrow frontal infundibulum make it a rather unpleasant area surgery.
to operate on for many surgeons.
The goal of the surgery is not only to achieve an adequate
frontal outflow tract to relief the patient’s symptoms but to 10.2 Indications
maintain this result in time. This can be achieved by remov-
ing all the cells of the frontal recess while respecting the The most common indication for endoscopic frontal sinus-
mucosa of the “outside walls” or the anatomical limits, com- otomy Draf IIA is chronic frontal sinusitis with or without
bined with good postoperative care. polyps, after an adequate medical treatment has failed [2]. In
A frontal sinusotomy is also a technically challenging the context of a diffuse sinus inflammation without opacifi-
surgery which requires the ability to operate with angled cation of the frontal sinus itself, the clearance of the frontal
instruments using angled scopes. This difficulty results in a recess is recommended if the surgeon is comfortable with the
steeper learning curve than with other sinuses, often creating procedure and can perform it safely. This pro-active or rather
frustration for novice surgeons. However, once the surgeon aggressive philosophy is not shared by everyone, but is the
usual choice of the authors. Nevertheless, if a surgeon is not
experienced enough, it is better to only perform a complete
Supplementary Information The online version contains supplementary ethmoidectomy and a Draf I, which includes a complete
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_10].
removal of the superior uncinate with preservation of the
agger nasi cell, avoiding the manipulation of the frontal
J. Viera-Artiles (*)
infundibulum at all. If this area is not correctly cleared, scar-
Department of Otolaryngology, Marqués de Valdecilla University
Hospital, Research and Innovation Surgery Group-IDIVAL, ring and osteoneogenesis can easily lead to stenosis, obstruc-
Santander, Spain tion, and worsening of the symptoms.
R. Megía Draf IIA can also be indicated to achieve drainage and
Department of Otolaryngology – Head and Neck Surgery, marsupialization of frontal mucoceles; however, if the final
University Hospital Marqués de Valdecilla, Santander, Spain size of the frontal sinusotomy is not wide enough, mucoceles
D. Lobo tend to recur. For this reason, the authors prefer expanded
Department of Otolaryngology, Marqués de Valdecilla University approaches in those cases.
Hospital, Valdecilla Biomedical Research Institute, Santander,
Spain
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 141
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_10
142 J. Viera-Artiles et al.

10.3 Schematic Description (Anatomy-­ yracea (laterally), exposing the frontal sinus cavity. This usu-
Expected Result) ally requires the removal of the ANC, the bulla, and the cells
above them, preserving the mucosa at the level of the skull
The frontal sinus drains into the frontal recess, a space occu- base both medially and laterally [4], Fig. 10.1.
pied by cells which shape the drainage pathway. During the
surgery these cells should be removed and the frontal sinus
should drain directly into the ethmoid cavity. 10.4 Preoperative Tips (Individual Risk
It is highly important to know the anatomical limits of the Factors, Radiology, Instrumentation)
frontal recess which are: medially the vertical lamella of the
middle turbinate and the lateral lamella of the cribriform plate 10.4.1 Individual Risk Factors
and laterally the lamina papyracea and lacrimal bone. The pos-
terior limit is usually marked by the anterior ethmoid artery and There are three main complications during a frontal sinusot-
the anterior skull base. The anterior limit is the nasal process of omy Draf IIA.  The most worrisome is the bleeding of the
the frontal bone or the frontal beak and the superior limit is the AEA, which could lead to a retrobulbar hematoma due to the
opening of the frontal sinus itself. The narrowest area between retraction of the artery into the orbit and eventually end up in
the frontal sinus and the frontal recess, usually at the level of blindness if it is not rapidly identified and solved. Hanging
the frontal beak, is called the frontal infundibulum. arteries running below the skull base in a mesentery without
The cells within the frontal recess can be classified a bony cover can easily be damaged while removing cells
depending on their position and relationship with the agger from the frontal recess and should be appropriately identified
nasi cell (ANC) and the ethmoid bulla. The ANC is the most before starting the procedure.
anterior ethmoid cell and can be located above the insertion Second, the penetration of the skull base subsequently
of the middle turbinate in the lateral wall (the axilla). The causes a CSF leak and a possible meningitis or other brain
cells above the ANC are called supra-agger cells and those infections. The most common area to cause a CSF leak is the
pneumatizing inside the frontal sinus are called supra-agger-­ posteromedial area in the ethmoid cavity and this complica-
frontal cells, following the new international consensus. tion is more frequent during a posterior ethmoidectomy.
Similarly, cells above the ethmoid bulla, which is a very con- Usually, the risk decreases during a frontal sinusotomy with
sistent cell usually present in all patients, are called supra-­ angled scopes and angled instruments, especially with 90°
bullar cells and supra-bullar-frontal cells if they are deep into instruments. In patients with deep olfactory fossa, care must
the sinus [3]. (For more information, see Chap. 3.) be taken as this means a larger medial wall of the frontal
To perform a Draf IIA, the frontal sinus should be opened recess with a significant amount of thin bone. The position
between the middle turbinate (medially) and the lamina pap- and length of the lateral lamella of the cribriform plate should
be analyzed before the surgery.
Third, penetrating the orbit during a frontal sinusotomy
used to be more common before the standardization of
angled scopes. Any orbital dehiscence should be noted
before starting the procedure. Furthermore, visualizing the
tip of your instrument every time it is inserted in the frontal
sinus helps to prevent this complication, as the yellowish
color of the orbital fat is usually easily identified [5].

10.4.2 Radiology

The CT scan helps to determine not only the risk factor

involved in complications but also to assess the difficulty of
the procedure. The key to successful frontal sinus surgery is
understanding the anatomy, which requires not only a careful
study of the CT scan images but also the mental transforma-
tion of the 2D images (in the 3 axes) to a 3D disposition of
the cells within the frontal recess. The configuration of the
frontal cells is better visualized using CT scan in the sagittal
view. However, the axial cuts are better to identify the path-
way of the frontal sinus drainage. With time and experience,
Fig. 10.1  Representation in a parasagittal CT scan of the endoscopic
vision with a 70-degree scope after a complete ant-post ethmoidectomy
the surgeon will learn to correlate each CT with the surgical
and complete removal of the cells of the frontal recess findings.
10  Cells Removal: Draf Type I and IIA 143

A thorough examination of the CT scan prior to the surgi-

cal procedure is mandatory. For this reason, using a CT
checklist is good practice not only for residents but for those
with lower experience in sinus surgery.
The classical frontal recess cells classification is the Kuhn
classification [6]. Even though it has been widely used in the
past, this classification only takes into account the coronal
plane, whereas the sagittal plane gives very important informa-
tion about the cells that influence the frontal sinus outflow tract.
For this reason, a new classification (IFAC) has been proposed
by an international panel of experts and the names of the cells
in this chapter follow this classification. The authors strongly
recommend the lecture of this document [3] (Fig. 10.2).
The antero-posterior (A-P) diameter at the frontal infun-
dibulum and the frontal beak give the surgeon information
about the possible final size of the frontal sinusotomy. A very
short A-P diameter may be an indication of drilling and will
likely require a Draf III approach rather than a Draf IIA.
The thickness of the bony septations in the frontal recess
also gives the surgeon useful information about how difficult
the procedure might be. Thick septations are more difficult to
break and the frontal sinus outflow tract might be harder to
find. Also, in previously operated patients, osteoneogenesis
can develop in raw bone areas where mucosa stripping
occurred, and those areas might require drilling.
The CT scan analysis is not only necessary to plan the sur-
gical approach but to prevent complications. For example, the
configuration of an AEA is highly important as an artery run-
ning in the skull base makes a procedure safer than a hanging
artery running in a mesentery, which can be easily damaged.
Also, a Keros type 3 which means a deep olfactory fossa
(more than 7  mm in depth) also implies a wider lateral
lamella of the cribriform plate, so the surgeon must be aware
of this anatomic configuration to avoid penetrating the skull
base through this delicate area.

10.4.3 Instrumentation

The frontal sinus is located in a coronal plane, thus angled

scopes and instrumentations are key to perform a successful
dissection. The author prefers a 70-degree scope; however,
30-degree or 45-degree can be employed.
Even though it might be counter-intuitive, using 90-degree
instruments is safer than 70° because this last one points
toward the skull base when it is placed deep into the middle Fig. 10.2  CT scan of a patient with a right supra-agger-frontal cell and
meatus, whereas the 90-degree instruments turn upward into a supra-bullar cell
the frontal sinus itself, making it more difficult to inadver-
tently penetrate the skull base.
Frontal sinus suction cannulas, seekers, and 90-degree the frontal recess. A frontal sinus punch, backward cutting
curettes are useful to locate the outflow tract. Some of them (also known as the “cobra”) is very helpful for removing the
can also be tractable and used along a navigation system. In frontal beak, making the final A-P diameter bigger, but a cir-
addition, a combination of thru-cutting and grasping giraffes cular cutting punch can also be employed. Moreover, a
can be used to manipulate and remove bony septations within 90-degree blade for the microdebrider makes it easier to
144 J. Viera-Artiles et al.

remove redundant mucosa in the most cranial aspect of the than the CT scan) and the suction cannula cannot be com-
frontal recess. pletely introduced, chances are that this is the roof of a
Using an intraoperative navigation system can be helpful, supra-agger/bullar-frontal cell that might have been
not only for inexperienced surgeons, but for safety and edu- missed during the CT scan examination. Going behind the
cational reasons. Expert surgeons might find it helpful for posterior wall of this cell with a frontal prove if the cell is
revision surgeries, to prevent unexpected situations or to a supra-agger-­frontal or in front of the anterior wall of the
assist in solving anatomic doubts during the procedure. The cell if it is a supra-bullar-frontal will allow the location of
navigation should not be used to tell us where we are, but to the real frontal sinus. However, if a very deep frontal cell
confirm that we are where we wanted to be [7]. cannot be completely removed, trying to break up the
remaining partitions and crush them back, leaving the
largest A-P diameter possible is a good technique.
10.5 Pearls and Potential Pitfalls • Do not try to enlarge the A-P diameter anteriorly if there
is not a prominent frontal beak but a thick block of bone.
10.5.1 Pearls Using instruments like the Bachert forceps (also known
as the “cobra”) or drilling in this area would likely dam-
• Performing a complete anterior and posterior ethmoidec- age the mucosa and increase the chances of stenosis due
tomy allows a better placement and freedom of movement to scarring if it is not properly enlarged.
of the instruments in the middle meatus, thus, helping to
perform a better dissection of the frontal recess.
• Sometimes it is not easy to differentiate the AEA from a 10.5.2 Pitfalls
skull base bony septation. A useful tip is to understand the
direction of the artery, which always comes posteriorly • Care must be taken in the posterior aspect of the ethmoid
from the orbit and runs through the skull base to enter into cavity in case of an unusual finding of a hanging posterior
the medial aspect of the lateral lamella of the cribriform ethmoid artery that could bleed if it is damaged and in
plate anteriorly. The dissection of the bony septations sur- patients with big Onodi cells, where the complete dissec-
rounding the AEA should be performed carefully and, in tion of the posterior ethmoid could lead the instruments
case of difficult identification of the artery, it is preferable close to the optic nerve and/or the internal carotid artery.
to leave some septations behind. • Exposed bone can lead to stenosis. The exposed bone can
• Moreover, when exploring the nasal cavity with a 0-degree suffer an inflammatory process leading to bone-­
scope after an ethmoidectomy, the AEA is usually located remodeling and the generation of new bone. This osteo-
superiorly in the nasal cavity and in the endoscopic image. neogenesis, if it happens in a previously narrow space,
If we change to a 70-degree scope, the AEA is going to can easily cause a complete stenosis of the frontal sinus
appear lower in the endoscopic image, while the frontal with future complications of frontal sinusitis and
recess and the frontal sinus are going to appear more mucoceles.
superiorly. • If bleeding from the AEA occurs, it is best to cauterize it
• In the case of a very inflamed or polypoid mucosa, where as medially as possible, using either a monopolar cautery
the cells of the frontal recess cannot be properly identi- (malleable single-use suctions) or bipolar (Stammberger
fied, a superficial-to-deep approach can be helpful to find bipolar). The artery can retract into the orbit and cause a
the outflow tract. Removing septations and mucosa medi- retrobulbar hematoma which requires imminent orbital
ally in the frontal recess, away from the lateral margins decompression and often canthotomy/cantholysis.
(the lamina papyracea and the lateral lamella of the crib-
riform plate), will eventually reveal the roof of the cells in
the frontal recess. Gently pushing with a suction cannula 10.6 Surgical Procedure Step by Step
or a frontal probe will help to localize the frontal outflow
tract. Generally, it is not a good idea to break through the 10.6.1 Access
roof of a frontal cell because a CSF leak can be created if
the skull base is mistaken with a cell. Before even approaching the ethmoid cavity, access to the
• A normal-sized frontal sinus is usually a well aeriated frontal sinus can be limited by the nasal septum. As a thumb-­
cavity that can host the full length of an angled frontal nail rule, if the middle turbinate axilla cannot be visualized
sinus suction cannula. If after removing all the cells in the after introducing a 0-degree scope in the nasal cavity, the
frontal recess only a small-sized sinus can be seen (smaller septum should be addressed before starting the sinusotomy.
10  Cells Removal: Draf Type I and IIA 145

10.6.2 Uncinectomy, Anterior and Posterior In some cases, after performing the axillary flap, a frontal
Ethmoidectomy sinusotomy can be completed with a 0-degree scope [9].
However, a combination of this approach with the use of
To set up for a frontal sinusotomy, a complete anterior and pos- angled scopes might allow surgeons to remove more difficult
terior ethmoidectomy should be performed. The first step cells like supra-agger-frontal and supra-bullar-frontal cells
nonetheless is the complete removal of the vertical portion of invading the frontal sinus.
the uncinate process, preferable in a retrograde fashion. A Draf
I procedure involves complete removal of the anterior ethmoid
cells and uncinate process surrounding the frontal recess. 10.6.4 Understanding the 3D Anatomy
The goal of the ethmoidectomy is to expose both the lat- of the Frontal Recess Cell
eral wall (lamina papyracea) and medial wall (the middle
turbinate) of the ethmoid, leaving their mucosa intact. The To locate the frontal sinus outflow tract, it is highly recom-
anterior skull base should be completely exposed as well. mended to previously identify the disposition of the frontal
However, as the skull base is lower in the posterior aspect of sinus cells and, using the axial cuts of the CT scan, identify
the nasal cavity, after removing the posterior ethmoid cells the frontal sinus outflow tract.
the skull base can be more easily identified posteriorly than CT scan analysis should be done prior to the beginning of
anteriorly. The anterior portion is going to be hidden by the the procedure. The frontal recess cells and frontal sinus
cells of the frontal recess due to the curvature of the skull draining pathway must be identified. A sinus navigation sys-
base. Thus, performing a dissection in a posterior to anterior tem can be used to confirm the identification of every key
fashion is usually safer. Furthermore, performing dissection cell and the draining pathway during the surgery. Once the
medial to lateral helps to avoid skull base penetration at the roof of every key cell in the frontal recess (agger nassi,
level of the lateral lamella of the cribriform plate. supra-­bullar, or supra-agger cells) has been correctly identi-
In the anterior aspect of the ethmoidal cavity, there is an fied, the outflow tract should be located. The more anterior or
inflection point where the skull base turns upward. If the dis- posterior position of the outflow tract depends on the size of
section of the ethmoid cavity has been performed with a the supra-bullar or supra-agger cells. If a supra-bullar cell is
0-degree scope while preserving the anterior attachment of dominant, the outflow tract is going to be located more ante-
the middle turbinate to the lateral wall (the axilla), chances riorly. However, if the dominant cell is a supra-agger, the
are that the cells from the frontal recess are still intact. outflow tract is going to be pushed backward. Similarly,
Using an angled scope (the author prefers the 70-degree intersinus frontal cells push the outflow tract laterally, while
scope) placed in the middle meatus and pointing upward, the prominent supra-orbital cells push it medially (Fig. 10.3).
skull base can be visualized posteriorly. Following the skull
base anteriorly, the frontal recess cells would hide the ante-
rior portion of the skull base past the inflection point. Our 10.6.5 Localizing the Fontal Sinus Outflow
mission now is to remove those cells, preserving the mucosal Tract
of the lateral, middle, and posterior walls of the frontal sinus.
Gently using a ball probe to avoid skull base penetration, the
outflow tract is usually located superomedially, adjacent to
10.6.3 Performing an Axillectomy (Optional) the vertical lamella of the middle turbinate, between the pos-
teromedial aspect of the ANC and anteromedially to the
Removing the anterior wall of the ANC with or without an supra-bullar cell (if present) or directly to the skull base.
axillary flap will allow a direct visualization of the frontal To confirm the correct localization of the outflow tract,
recess cells using a 0-degree scope and manipulation of the placing a 90-degree suction cannula or ball probe inside the
cells of the frontal recess with straight instruments. Wormald sinus should not meet any resistance. A navigation system
described the axillary approach to the frontal recess back in can be useful in cases of difficulties locating the outflow tract
2002 and involves removing the anterior wall of the ANC or to help identify supra-bullar/agger-frontal cells that go
through the middle meatus axilla [8]. The axillary flap deep into the sinus.
reduces exposed bone, hence, reducing crusting and improv- Finding the outflow tract early in the sinusotomy makes
ing the immediate postoperative results; however, it could be the procedure easy. After the way to the sinus has been found,
skipped and the removal of the axilla can be performed with the rest of the procedure consists of safely removing the cells
a Kerrison Rongeurs, however this window is more prone to within the recess while respecting the mucosa of the “outside
scarring than with the mucosal flap. walls” (Fig. 10.4).
146 J. Viera-Artiles et al.

Fig. 10.3  Patient with a right supra-orbital cell and with an intersinus frontal cell. Results after frontal sinusotomy Draf 2A

a b d

Fig. 10.4 (a) View of the supra-agger frontal cell using a 70-degree scope after the ethmoidectomy. (b) Parasagittal CT scan. (c) Simulation of
the parasagittal CT scan after performing a complete ethmoidectomy (d) Final result of the Draf 2A

10.6.6 Removing the Cells of the Frontal 10.6.7 Removing the Cells of the Anterior

Recess Skull Base (Tunnel Vs Funnel)

Using a combination of angled instruments, the frontal After the outflow tract has been found, if only the cells within
recess cells can be removed with different techniques: the frontal recess are removed (without addressing the bony
sharply cutting the cells using angled through-cutting instru- septations of the rest of the skull base), the final shape of our
ments or detaching them with a 70/90-degree curette and frontal sinusotomy is going to be tunnel-shaped. Therefore,
removing the bony septations with a giraffe forceps. The if we continue the dissection posteriorly, removing all these
remanent mucosa can be removed using an electric micro- septations and completely exposing the skull base, the final
debrider with a 90-degree angled shaver blade, preserving shape is going to be shaped like a funnel with the bigger A-P
the mucosa circumferentially at the level of the infundibu- diameter possible, reducing the options of scar-close stenosis
lum. If the remanent mucosa is attached to the mucosa of the (Fig. 10.6).
orbit or the skull base, using forceps to remove it might tear
it and expose raw bone. Therefore, using a cutting instru-
ment like the shaver blade is more convenient in this deli- 10.6.8 Irrigation of the Sinus
cate area.
The microdebrider, nevertheless, should be used carefully At the end of the sinusotomy, it is good practice to irrigate
and after identifying all the landmarks. Rotating the tip and with saline the interior of the frontal sinus to clean it from
turning the cutting edge away from the orbit until this is mucus/mucin/pus and remove scattered pieces of bony
clearly identified is a safer way to perform this step. The septations. This can be done by placing an angled suction
70-degree scope is very useful to continuously visualize the cannula inside the sinus and it is important to do it with
tip of the microdebrider (Fig. 10.5). correct visualization to confirm the placement. Also, gen-
10  Cells Removal: Draf Type I and IIA 147

a b

c d

Fig. 10.5  Occupied right frontal sinus. (a) Parasagittal CT scan. (b) View with 70-degree scope after ant-post ethmoidectomy. (c) Localization of
the frontal sinus outflow tract. (d) Results after frontal sinusotomy Draf 2A. Blue dot: supra-bullar frontal cell. Yellow star: agger cell

tly feeling the eyeball with a finger while irrigating, the 10.6.9 Preventing Lateralization of the Middle
surgeon could feel if the saline is entering into the orbit Turbinate
and stop the irrigation. This is a rare complication that
might occur in inexperienced surgeons and can rapidly Stenting the frontal infundibulum is a controversial tech-
increase ocular tension requiring imminent orbital nique that can be helpful in revision cases in patients with
decompression. high risk of stenosis. However, in a regular frontal sinusot-
148 J. Viera-Artiles et al.

Fig. 10.6  Representation of Dr. Janjua’s concept “tunnel vs funnel” in a parasagittal CT scan after a complete frontal sinusotomy Draf 2A

employed in the clinic, to remove those formations and clear

omy, the goal is to keep the sinus patent after the surgery
the frontal recess.
and for this the lateralization of the middle turbinate should
be prevented. To achieve this goal there are several tech-
niques; nevertheless, the preferred technique of the authors
is the placement of a 1 mm thick silicon sheet, cut in a spe-
References
cific fashion, inside the ethmoid cavity. This sheet can be 1. Wormald PJ.  Surgery of the frontal recess and frontal sinus.

removed after 2–3 weeks and is usually well tolerated by Rhinology. 2005;43(2):82–5.
patients. 2. Chan Y, Melroy CT, Kuhn CA, Kuhn FL, Daniel WT, Kuhn

FA.  Long-term frontal sinus patency after endoscopic frontal
sinusotomy. Laryngoscope. 2009;119(6):1229–32. https://doi.
org/10.1002/lary.20168.
3. Wormald PJ, Hoseman W, Callejas C, et  al. The International

10.7 Postoperative Tips Frontal Sinus Anatomy Classification (IFAC) and classification
of the Extent of Endoscopic Frontal Sinus Surgery (EFSS). Int
Maintaining a moisturized nasal mucosa helps in the healing Forum Allergy Rhinol. 2016;6(7):677–96. https://doi.org/10.1002/
process after endoscopic sinus surgery. In the case of a fron- alr.21738.
4. Wormald PJ.  The agger nasi cell: the key to understand-

tal sinusotomy in a patient with an inflammatory condition, ing the anatomy of the frontal recess. Otolaryngol Head
steroids-impregnated rinses have been shown to be more Neck Surg. 2003;129(5):497–507. https://doi.org/10.1016/
beneficial than steroid sprays, possibly due to the better dis- S0194-­5998(03)01581-­X.
tribution achieved inside the nasal cavity. It has also been 5. Korban ZR, Casiano RR. Standard endoscopic approaches in frontal
sinus surgery: technical pearls and approach selection. Otolaryngol
demonstrated that expanded approaches such as Draf III Clin N Am. 2016;49(4):989–1006. https://doi.org/10.1016/j.
increase the distribution inside the frontal sinus in nasal rins- otc.2016.03.022.
ing, which is an argument in favor of removing the anterior 6. Folbe AJ, Svider PF, Eloy JA. Anatomic considerations in frontal
wall of the ANC. sinus surgery. Otolaryngol Clin N Am. 2016;49(4):935–43. https://
doi.org/10.1016/j.otc.2016.03.017.
It is important to take the time to explain to patients the 7. Metson R, Sindwani R. Endoscopic surgery for frontal sinusitis-a
correct way to perform the sinus douches and try to involve graduated approach. Otolaryngol Clin N Am. 2004;37(2):411–22.
them in their treatment as it usually takes days or weeks for https://doi.org/10.1016/S0030-­6665(03)00153-­1.
their symptoms to begin to improve. This investment of time 8. Wormald PJ.  The axillary flap approach to the fron-

tal recess. Laryngoscope. 2002;112(3):494–9. https://doi.
will likely pay off with better postoperative results. org/10.1097/00005537-­200203000-­00016.
After removing the silicon sheets, suctioning the mucus 9. Spielman DB, Kim M, Overdevest J, Gudis DA. Zero-degree endo-
or squeezing the polyps circumferentially in the frontal scopic visualization of the frontal sinus predicts improved topical
infundibulum helps to reestablish the sinus drainage. In cases irrigation delivery. Laryngoscope. 2021;131(2):250–4. https://doi.
org/10.1002/lary.28654.
of synechia formation, through-cutting instruments can be
 The Vertical Bar Concept in Frontal
Recess and Frontal Sinus Surgery 11
Gustavo Coy, Flavia R. Demarco, Camila S. Dassi,
João Mangussi-Gomes, and Aldo C. Stamm

11.1 Introduction by-­step approach to the FS as well as discuss the decision-­

making process associated when choosing this technique.
Surgery of the frontal sinus (FS) and frontal recess (FR)
remains a challenge despite advances in instrumentation and
visualization. The frontal sinus drainage pathway (FSDP) 11.2 Indications
has a conformation similar to an hourglass. The narrowest
point of this hourglass is the junction between the internal Draf and collaborators defined and classified the different
frontal ostium superiorly and the FR inferiorly [1, 2]. At this approaches to the FS according to the degree of ventilation
site, surgery of the FS is more at risk of failure. This may achieved [6, 7]. The VB concept was described by Stamm
happen not only secondary to disease severity, but also to and collaborators [4]. It is a systematization to the Draf IIa
poor dissection and instrumentation, as inadvertent injury to approach that is based on complete understanding of the
mucosa may cause stenosis at the FSDP [3]. Furthermore, anatomy of the FR and FSDP [5]. A successful VB approach
inadequate understanding of the FR anatomy and of each should allow for the FS to remain patent post-operatively and
patient’s anatomical particularities increases the risk of fail- ensure irrigation of topical steroids as well as in-office
ure secondary to insufficient dissection and ventilation of the instrumentation of this sinus. Therefore, it is indicated for
FS. situations in which a Draf IIa is a sufficient technique for
The vertical bar (VB) is a vertical septation at the FR. It is aeration of the FS.  For virtually all patients with primary
formed by the junction of the superior attachment of the chronic rhinosinusitis (CRS) that have not undergone previ-
uncinate process (UP) with the medial wall of the agger nasi ous surgery, the VB concept is an excellent option, especially
cell (ANC) and is used as a landmark to access the FS. The when there is favorable anatomy, and the disease is not
vertical bar (VB) concept aims to systematize the Draf IIa severe. When CRS inflammation is severe, as seen in sys-
approach to the FS [4]. It adds method and simplifies this temic conditions like aspirin-exacerbated respiratory dis-
approach, consequently improving patient outcomes. It is ease, immunodeficiency, and granulomatosis with
based on thorough understanding of the FR cellularity, of the polyangiitis, failure rates tend to be higher as well as the
FSDP and on each patient’s unique anatomy as seen on need for revision surgery [8–10]. Likely, these patients will
imaging [5]. In this chapter, we will show the author’s step-­ more frequently benefit from extended approaches such as a
Draf IIb or Draf III.
In revision cases, the prior study of the patient’s com-
Supplementary Information The online version contains supplementary puted tomography scan becomes even more important. If
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_11]. there was a failure to aerate the frontal sinus, either from
incomplete dissection at the FR or because a more conserva-
G. Coy tive technique was undertaken, the VB concept could be con-
São Paulo ENT and Skull Base Center, Edmundo Vasconcelos sidered. Patients who have undergone a previous
Hospital, São Paulo, SP, Brazil comprehensive Draf IIa, where there was complete clearance
Department of ENT, Pontifical Catholic University of Campinas, of all ethmoid partitions at the FSDP, should be considered
Campinas, SP, Brazil as having failed this approach and will presumably benefit
F. R. Demarco · C. S. Dassi · J. Mangussi-Gomes from a more extended approach [3, 11].
A. C. Stamm (*)
São Paulo ENT and Skull Base Center, Edmundo Vasconcelos
Hospital, São Paulo, SP, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 149
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_11
150 G. Coy et al.

11.3 Schematic Description The UP is a thin ethmoid lamella that is oriented in an

anterior superior to a posterior inferior direction (Fig. 11.1).
When the FS is approached via the VB concept, it is impera- At its superior attachment, the UP is in continuity with the
tive to understand the relationship between the UP, the ANC, medial wall of the ANC and forms the “vertical bar,” a verti-
the bulla ethmoidalis (BE), the VB, and the middle turbinate cal septation that can be used as a landmark to access the
(MT). How each of these ethmoid partitions and cells i­ nteract FS.  Normally the ANC is not in contact with the BE and
determines the location of the frontal sinus drainage pathway the vertical lamella of the MT. Consequently, this will bring
(FSDP). the FSDP to a position medial and posterior to the VB [12].

a b

c d

Fig. 11.1  Cadaveric dissection of a right nasal cavity. (a) The UP is is fractured laterally to expose the FSDP. Uncinate process (1), middle
medialized and detached from the lateral nasal wall with a sickle knife. turbinate (2), lateral nasal wall (3), agger nasi cell (4), bulla ethmoidalis
(b) Identification of the cells at the FR after resection of the UP. (c) The (5), vertical bar (6), frontal sinus (7), and frontal sinus drainage path-
VB is medialized to identify the FSDP. (d) The medial wall of the ANC way (*)
11  The Vertical Bar Concept in Frontal Recess and Frontal Sinus Surgery 151

Finally, topical vasoconstriction is performed with

4 adrenaline-­soaked neuro patties at a concentration of 1:2000.
Surgery via the VB concept starts with a 0-degree endo-
scope, but angled scopes are needed as dissection is carried
1 out superiorly, into the FSDP and FS. The authors prefer 45-
and 70-degree scopes to allow full visualization of the
FR. Instrumentation is also key in FS surgery. A FS set with
angled instruments is necessary for a complete dissection.
This set should ideally have a wide range of FS instruments
with an angulation of at least 60°. Surgery of the FS should not
be attempted without adequate instruments, as there is a risk of
5 post-operative failure from injury to the frontal recess or from
2
incomplete dissection of the FSDP.  The authors typically
access the FS via the VB concept with a set that contains the
3
following angled instruments: suction tips, curettes, ostium
seekers, Kerrison Rongeurs, thru-cutting forceps, grasping
forceps, mushroom forceps, and an angled microdebrider.

11.5 Pearls and Potential Pitfalls

Fig. 11.2  Two and a half years post-operative endoscopic view of a
healed left frontal sinusotomy, approached via the VB concept. Frontal To have complete intra-operative awareness of each patient’s
sinus (1), orbit (2), middle turbinate (3), frontal beak (4), skull base (5), unique anatomy, it is imperative that the surgeon studies the
and anterior ethmoidal artery (arrow)
patient’s CT scan before the procedure. As described previ-
ously, in most cases, the ANC is not in contact with the BE
Once the approach via the VB concept is finished, the dis- and MT, which brings the FSDP medial and posterior to the
section should look like a complete Draf IIa frontal sinusot- VB and ANC [12]. However, the pneumatization of the ANC
omy. The medial limit of the dissection is the vertical lamella can alter the FSDP anatomy. When the ANC is extensively
of the MT, laterally we will find the medial wall of the orbit, pneumatized in the mediolateral plane, it displaces the VB
anteriorly the nasal process of the frontal bone (the “frontal medially towards the vertical lamella of the MT. This makes
beak”), and posteriorly the transition between the posterior the FSDP narrow and dislocates it posteriorly. In contrast, in
table of the FS and the skull base (Fig. 11.2). a poorly pneumatized ANC, the VB will not be in contact
with the vertical lamella of the MT, which brings the FSDP
to a medial position in relationship to the ANC [17].
11.4 Pre-operative Tips The anteroposterior diameter of the frontal sinus should
be checked on the CT scan before surgery. When the skull
As with all FS approaches, visibility and access are cru- base slope is flat and/or when the frontal beak is prominent,
cial for the VB concept, as surgery happens in a very nar- the workspace may become narrow. This increases the likeli-
row region. If there is excessive bleeding in the surgical hood of persistent FS disease from cicatricial stenosis of the
field, if there is not enough working space, or if the ergo- FS ostium. In such situations, an extended approach, such as
nomics are inadequate to dissect the FS, the FS dissection Draf IIb or Draf III, may be necessary (Fig. 11.3) [3, 18].
may be incomplete and there will likely be an increase in Any complex cellularity of the FS must also be assessed
surgical time. Therefore, a few key points preferred by the on imaging prior to surgery. Cells that pneumatize into the
authors to improve surgery execution will be briefly FS, like supra agger frontal and supra bulla frontal cells, do
summarized. not preclude the VB concept, as most of these cells can be
The authors favor positioning the patient in a 15° reverse managed via this approach (Fig. 11.4). When the pneumati-
Trendelenburg position, with the neck extended and rotated zation of these cells is extensive, there is a greater probability
towards the surgeon. This improves ergonomics and reduces of incomplete dissection and of causing injury to the mucosa
blood loss [13]. To further decrease blood loss, the surgery is from excessive manipulation of the FR, particularly if the
performed under hypotensive total intravenous anesthesia anteroposterior diameter is narrow. In this setting, there is
and the heart rate is kept at less than 60 bpm [14, 15]. When risk of failure and the surgeon should consider an extended
there are no contraindications, 1 g of intravenous tranexamic approach pre-operatively or be prepared to convert to one
acid is administered at the beginning of the procedure [16]. during surgery.
152 G. Coy et al.

11.6 Surgical Procedure Step-by-Step

11.6.1 Initial Endoscopic Examination

Initially, with a 0-degree endoscope, the surgeon must

study the patient’s anatomy. The UP, ANC, BE, and vertical
lamella of the MT should all be identified prior to the begin-
ning of the dissection. If the patient presents a septal devia-
tion that narrows the access to the frontal sinus, a septoplasty
is performed. Ideally, the surgeon should be able to visual-
ize the axilla of the MT before the FS is addressed
(Fig. 11.5).

Fig. 11.3  Sagittal reconstruction of a computed tomography scan that

illustrates a narrow anteroposterior diameter on a flat skull base. This 11.6.2 Uncinectomy
patient had significant inflammation secondary to chronic rhinosinusitis
with nasal polyps and was not considered suitable for the VB concept. Dissection begins with a 0-degree endoscope. The MT is
He underwent a Draf III approach
carefully medialized with a freer elevator protected with
neuro patties. With an ostium seeker, the UP is also medial-
ized and an uncinectomy is performed. The UP can be
resected either with the sharp end of a Freer elevator (or
sickle knife) or with a backbiting forceps. Regardless of the
instrument used, the UP should be resected all the way to its
attachment to the lateral nasal wall in a superior and inferior
direction (Fig. 11.6). The remaining fragments of the hori-
zontal and vertical portions of the UP can be resected with a
0- or 12-degree microdebrider [5].

4
1

Fig. 11.4  Sagittal section of a computed tomography scan that illus-

trates a large supra bulla frontal cell in a patient with central compart-
ment atopic disease. Despite the prominent frontal beak and cellularity
of the frontal recess, this patient was approached via the VB concept 5

FS mucoceles can be addressed via the VB concept, espe- 2

cially when the anteroposterior diameter is not narrow or
3
when the lesion is not in a position that is too superior into the
FS. This may be an impediment to the VB concept. Regarding
benign tumors, such as inverted papillomas, in specific cir-
cumstances these can be approached with the VB concept.
Resection of small lesions in a FS with a wide anteroposterior
diameter is often feasible. Bigger lesions, particularly ones
with extensive attachment to the FS walls, are better addressed
with an extended approach. Regarding malignant lesions, vir-
tually all are better addressed via extended endoscopic
approaches to increase intra-operative access and visibility.
Fig. 11.5  Endoscopic examination of the left nasal cavity. Vertical
Combined open and endoscopic approaches are sometimes
lamella of the MT (1), uncinate process (2), bulla ethmoidalis (3), pro-
necessary for both benign and malignant tumors according to jection of the agger nasi cell into the lateral nasal wall (4), and nasal
size, histology, and attachments [19, 20]. septum (5)
11  The Vertical Bar Concept in Frontal Recess and Frontal Sinus Surgery 153

4
2 1 2

1
3

Fig. 11.6  Endoscopic view of the left nasal cavity. The uncinectomy is
Fig. 11.7  Endoscopic view of the left frontal recess. The anterior wall
being performed with a Freer elevator. Uncinate process (1), bulla eth-
of the agger nasi cell was resected with a Kerrison Rongeur. Vertical bar
moidalis (2), and middle turbinate (3)
(1), agger nasi cell (2), bulla ethmoidalis (3), and vertical lamella of the
middle turbinate (4)
11.6.3 Identification of the Frontal Sinus
Drainage Pathway

With an angled, 45- or 70-degree endoscope, the attach-

ments of the UP are identified. When the UP has an attach-
ment to the lamina papyracea superiorly, it creates a
dome-like formation called the terminal recess (TR). Both
the TR and the ANC are sometimes confused as they 1
appear anterior-­superiorly as a cul-de-sac that impairs the
visualization of the FSDP [21]. The next step involves the 2
resection of the TR (when present) and of the anterior wall
of the ANC (with the preservation of its medial). This can
be achieved using an angled microdebrider, angled thru-
cutting instruments, or a Kerrison. As discussed before, the
medial wall of the ANC is continuous with the UP and
forms the “vertical bar.” The VB serves as a landmark to
find the FSDP (Fig.  11.7). The FSDP will normally be 3
medial, posterior, or posteromedial to the VB [12]. With
this in mind, a frontal ostium seeker will be introduced
posteromedially to the VB in search of the FSDP.  The
Fig. 11.8  Endoscopic view of the left frontal recess. The medial wall
FSDP may be difficult to identify as an airspace when of the agger nasi cell is being fractured with a curette to expose the
there is significant tissue edema or extensive pneumatiza- frontal sinus. Medial wall of the agger nasi cell (1), frontal sinus (2),
tion of the cells at the FR.  In this situation, the surgeon and bulla ethmoidalis (3)
should look for a mucosa-mucosa plane that can suggest
the location of the FSDP. After the FSDP is identified, a FS preservation of the outer walls of the FR, in order to avoid
curette (or frontal ostium seeker) is used to fracture the post-­operative scarring and obstruction (Fig. 11.9).
medial wall of the ANC antero-laterally to further expand
the FSDP and identify the FS (Fig.  11.8). Then, with
angled instruments like Kerrison Rongeurs and thru-cut- 11.6.4 Intact Bulla Technique
ting and grasping forceps, the FR ethmoid septations are
carefully resected and the bone fragments removed. The The BE is usually kept intact for as long as possible. This
redundant mucosa is removed with the microdebrider, with aids in finding the FSDP and will initially serve as the poste-
154 G. Coy et al.

2
3
2 4

Fig. 11.9  Endoscopic view of the left frontal sinusotomy limits.

Fig. 11.10  Eight weeks post-operative endoscopic view of a healed
Frontal beak (1), orbit (2), skull base (3), and vertical lamella of the
right frontal sinusotomy, approached via the VB concept. Frontal beak
middle turbinate (4)
(1), vertical lamella of the middle turbinate (2), orbit (3), skull base (4),
and anterior ethmoidal artery (arrow)

rior limit of the dissection. Additionally, the authors find that suctioned to ensure its patency. If synechiae is identified,
the preservation of the BE at the beginning of the procedure these are carefully divided. When surgery happens with min-
protects the skull base and anterior ethmoidal artery (AEA) imal injury to mucosa, nearly perfect healing is expected to
[22]. Removal of the cells at the FR is carried out with the happen at the 6-week mark (Fig. 11.10).
BE intact using angled instrumentation. Once the FR cells
are cleared, the BE is resected and care is taken to avoid
injury to the skull base and AEA. At the end of the proce-
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inhalational anesthesia on the surgical field during endoscopic Otorrinolaringol. 2007;73(2):204–9. https://doi.org/10.1590/
sinus surgery. Am J Rhinol. 2005;19(5):514–20. https://doi. S0034-­72992007000200010.
org/10.1177/194589240501900516. 22. Ji J, Zhou M, Li Z, Wang T, Cheng Y, Wang Q. Frontal sinus surgery
15. Kolia NR, Man L-X. Total intravenous anaesthesia versus inhaled anterior to the ethmoid bulla. Int Surg. 2013;98(2):149–55. https://
anaesthesia for endoscopic sinus surgery: a meta-analysis of doi.org/10.9738/CC37.
randomized controlled trials. Rhinol J. 2019;1:171. https://doi.
org/10.4193/Rhin19.171.
 Bone Removal. Grade 4-5: Partial
Removal of Frontal Sinus Floor. Draf II B 12
Humbert Massegur, Juan Ramon Gras-Cabrerizo,
and Juan Manuel Ademà

12.1 Introduction 12.2 Indications

Sometimes, depending on the pathology of the frontal sinus, If the previous type IIA procedure is smaller than 5 mm
a wider sinusotomy is necessary to achieve good and perma- Complications of acute rhinosinusitis
nent results. If the underlying pathology suggests that a type Frontal sinus tumor surgery
II A is too small to improve the underlying pathology of the Cystic fibrosis
frontal sinus, it can be necessary to perform a type II B. This Barotrauma
approach allows the widest unilateral access to the frontal Frontal sinus medial mucocele or mucopiocele
sinus (Figs. 12.1a–c and 12.2). Stenosis or failure of previous frontal surgery
In a newly created frontal ostium, there is a high possibil- Selected frontal sinus meningoencephalocele
ity of neo-osteogenesis [1, 2] which occurs in approximately Selected frontal sinus osteoma
25% of patients. It is mandatory to avoid circumferential
bone exposure to prevent stenosis [3]. If restenosis occurs or
if a type II A procedure has not been sufficient to improve the 12.3 Instrumentation
pathology, type IIB is a good option (Fig. 12.3).
The natural drainage of the frontal sinus is a narrow 45–70° endoscopes. The 45° optic is better with the lateral
ostium between the middle turbinate and the uncinate pro- connection of the light source to allow a wider angle of up-­
cess. The uncinate process has several variations and, as a down movement.
consequence, the anatomy can be very challenging even in Frontal sinus suction tube
the different sides of the same patient. Distinct cells of the SerpENT forceps (Fig. 12.4a)
anterior ethmoid may grow into frontal recess and even into Modified Kerrisson forceps (Fig. 12.4b)
the frontal sinus itself, causing misorientation during frontal Stammberger Punch 65° upturned
sinus surgery [4–6]. The well described by Stammberger Khun-Bolger frontal sinus curette
described as “the cap of the egg” the reminder dome of a Khun-Bolger Giraffe forceps (Fig. 12.4c)
frontal bullae or a cell that impedes the frontal sinus drain- Khun-Bolger frontal ostium seeker
age. Sometimes it is only necessary to remove it to obtain a Cupped jaws forceps 80° upturned (Fig. 12.4d)
good result, but in other cases it is not sufficient and a wider 70° angled sinus burrs with diamond and cutting heads
approach, such as type IIA or type IIB is mandatory. Castelnuovo forceps upturned

12.4 Pearls and Potential Pitfalls

Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_12].
Preserving the ethmoid bulla at the beginning of the proce-
dure is useful as a landmark. The anterior wall of the bulla is
H. Massegur (*) · J. R. Gras-Cabrerizo the posterior limit of the frontal recess dissection when a pre-­
ORL Department, Hospital de Sta Pau, Barcelona, Spain bullar approach is used and the patient has not been operated
e-mail: [email protected]
on before.
J. M. Ademà
ORL Department, Hospital General de Catalunya,
Barcelona, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 157
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_12
158 H. Massegur et al.

FS FS FS

S S S
LP LP LP
EB

UP
MT MT MT

IT MS IT MS IT MS

a b c

Fig. 12.1  Schematic drawing. (a) Normal anatomy, (b) Draf IIA, (c) Draf IIB. S septum, FS frontal sinus, LP lamina papiracea, EB ethmoid bulla,
UP unciform process, MT middle turbinate, IT inferior turbinate, MS maxillary sinus

CP
ET
FS OF

LP MT S

Fig. 12.2  Schematic drawing of a Draf IIB on the right nasal fossa. LC
Fig. 12.3  Endoscopic view of the right axillary area showing resteno-
cribriform plate, ETS ethmoid sinus, FS frontal sinus, OF 1st olfactory
sis of a previously performed Draf IIA. MT middle turbinate, Ax axil-
fiber, LP Lamina papyracea, MT resected middle turbinate, S septum
lary area

The lamina papyracea is the external lateral limit and an to fix the orotracheal ventilation tube on the left side of the
external landmark, so it is mandatory to dissect it before wid- patient's lips. The main problem of the frontal sinus surgery
ening the frontal recess. is that sometimes we cannot reach with the instrumentation
The nasal septum is the medial limit. the area we can see perfectly with the lens. Cervical hyperex-
The first olfactory fiber is a good landmark to know the tension may be useful in some cases.
posterior limit of the drilling. To have a better visualization, it is useful to take the time
After the opening of frontal recess (Draf I–Draf IIA) the using cotton pledges soaked with vasoconstrictor (oxy-
bulla ethmoidalis must be removed to find the anterior eth- metazoline or adrenaline) to prevent the endoscope from
moid artery as a new landmark, before drilling the floor of the becoming blurry. Furthermore, the use of a cleaning system
frontal sinus. Drilling is usually necessary because the medial for the optic is also advisable to have a better visualization of
bone of the frontal floor is thicker than the lateral floor. the surgical field.
To prevent difficulties and limitations of the movement of Mucosal flaps to cover the drilled bone may be useful to
the forceps and drills, it is necessary to advise the anesthetist avoid stenosis.
12  Bone Removal. Grade 4-5: Partial Removal of Frontal Sinus Floor. Draf II B 159

a b

c d

Fig. 12.4 (a) SerpENT forceps, (b) modified Kerrison forceps, (c) Khun-Bolger giraffe forceps, (d) cupped jaws forceps 80° upturned

to cover the drilled bone at the end of the procedure

12.5 Surgical Procedure Step by Step (Figs. 12.5, 12.6, 12.7, and 12.12).
The next step is the medial luxation of the middle turbi-
The concept of Draf IIB is the resection of the floor of the nate, uncinectomy and, following the anterior wall of the
frontal sinus between lamina papyracea and nasal septum bulla ethmoidalis (Fig. 12.8) probe the frontal recess.
and removing the head of the middle turbinate. Draf I and Draf IIB procedures are performed step by step
The procedure is different if it is the first operation or under endoscopic control with 45° optic. An anterior eth-
restenosis after a Draf I or Draf IIA (Video 12.1). In the last moidectomy is mandatory to facilitate the visualization of
case there are few landmarks available and it is mandatory to the anterior ethmoidal artery and the frontal recess, frontal
localize the lamina papyracea, lacrimal bone and, even, the ostium, and frontal infundibulum. Good exposure of the lam-
lacrimal sac. It is also advisable to dissect the first olfactory ina papyracea is essential to allow work on the floor of the
fiber at the beginning of the procedure and eventually remove frontal sinus.
the head of the middle turbinate to have the septum as a Removal of agger nasi cells allows for a better field and bet-
medial limit and landmark. ter post-op results. Kerrisson forceps are useful to remove these
In a patient without previous surgeries, it can be useful, as cells after dissecting the mucosa over them to create local nasal
a first step, to prepare an axillary flap [7] or septoturbinal flap flaps (axillary flap or septoturbinal mucosal flap) [8, 9].
160 H. Massegur et al.

Fig. 12.5  Endoscopic view of the left nasal cavity showing main land-
marks to identify in an unoperated patient. Ax axilla, AN agger nasi, MT Fig. 12.7  The flap is tucked between the turbinate and the septum to
middle turbinate avoid injuring it with the forceps or the burr. S septum, AxF axillary
flap, AN agger nasi

Fig. 12.6  Axillary flap (incision from agger nasi to the medial wall of
the middle turbinate over the axilla). AxF axillary flap, MT middle
turbinate
Fig. 12.8  The frontal recess has been widened and the middle turbi-
nate removed to proceed to the drilling of the frontal floor. AxF axillary
flap, FS frontal sinus, EB ethmoid bulla
The next step is to localize the first olfactory fiber
(Fig. 12.9) before removing the axilla and the most anterosu-
perior portion of the middle turbinate. The septum is a medial burr to widen the frontal recess to achieve a wide frontal
landmark for dissection. Sometimes it is possible to remove sinus neo-ostium.
the bone of the medial floor with forceps (Stammberger If possible, it is best to avoid removing the mucosa or
punch, modified Kerrison forceps, etc.) but it is more fre- drilling the posterior limit of the frontal floor to prevent
quent to use a curved drill with a cutting burr or diamond restenosis and to create pediculated flaps or free grafts of
12  Bone Removal. Grade 4-5: Partial Removal of Frontal Sinus Floor. Draf II B 161

Fig. 12.9  First olfactory fiber and anterior meningeal artery dissected
as the limit to avoid injury of the cribriform plate and CSF leak. AMA
Fig. 12.11  Axillary flap rolled up covering the medial anterior limits
anterior meningeal artery, OF olfactory fiber, FS frontal sinus
of the newly created frontal ostium. S septum, AxF axillary flap, FS
frontal sinus, LP lamina papyracea, AEA anterior ethmoid artery

Fig. 12.10  Draf IIB completed. The medial floor of the frontal sinus
has been drilled from lamina papyracea to the septum. AMA anterior
meningeal artery, AxF axillary flap, OF olfactory fiber, AEA anterior
Fig. 12.12  Left nasal fossa, endoscopic view of an agger nasal cell
ethmoid artery, LP lamina papyracea
invading the frontal recess after the removal of the anterior wall at
the level of the axilla. The axillary flap is folded between the septum
mucosa to cover the exposed bone (Figs. 12.10 and 12.11). and the remnant of the middle turbinate. AXf axillary flap, ANc agger
nasi cell
Circular injuries to the mucosa led to complete occlusion by
scarring in 25% of the patients [3].
Figures 12.6, 12.7, 12.8, 12.9, 12.10, 12.11, and 12.12 Finally, Figs. 12.15, 12.16, 12.17, 12.18, and 12.19 show
show the surgical steps of a Draf IIb on a cadaver dissection. the steps of a Draf IIb procedure in a patient with an inverted
Figures 12.13 and 12.14 show Draf IIa and IIb procedures papilloma.
with the limits of resection in both cases.
162 H. Massegur et al.

Fig. 12.14  Left nasal fossa. Endoscopic view of the frontal sinus after
a Draf IIB procedure with the lamina papyracea as lateral limit and the
Fig. 12.13  Left nasal fossa. Endoscopic view with a 45° optic lens of
septum as the medial limit. The anterior ethmoid artery has been cauter-
the frontal sinus after performing a Draf IIA procedure, with the lamina
ized. S septum, FS frontal sinus, LP lamina papyracea, AEA anterior
papyracea as lateral limit and middle turbinate as the medial limit. MT
ethmoid artery (cauterized)
middle turbinate, AEA anterior ethmoid artery, LP lamina papyracea,
FS frontal sinus

Fig. 12.15  CT scan of a 73 y.o patient with relapsed inverted papil- rhinosinusitis with nasal polyps. A sagittal view, B axial view, C&D
loma that invades the frontal sinus and maxillary sinus and blocks all coronal view, AEA anterior ethmoid artery, MT middle turbinate
the left nasal fossa. The right nasal fossa is also blocked by chronic
12  Bone Removal. Grade 4-5: Partial Removal of Frontal Sinus Floor. Draf II B 163

Fig. 12.15 (continued)

Fig. 12.16  Left nasal fossa. Endoscopic view of the case of inverted Fig. 12.17  Left nasal fossa. Endoscopic view of the frontal recess-­
papilloma invading the frontal sinus and blocking completely the nasal frontal sinus during a Draf IIB procedure. The inverted papilloma has
fossa. Pp inverted papilloma, S septum, AN agger nasi been completely removed. FS frontal sinus, MT middle turbinate, An
agger nasi, Ax axilla, AEA anterior ethmoid artery
164 H. Massegur et al.

Fig. 12.18  Left nasal fossa. Endoscopic view of an incomplete Draf Fig. 12.19  Left nasal fossa. Endoscopic view of a complete Draf IIB
IIB after removing the middle turbinate with a remnant of the medial with the medial frontal floor of frontal sinus reaching the medial limit
frontal floor. S septum, FS frontal Sinus, AEA anterior ethmoid artery, of the nasal septum (closer view). S septum, FS frontal sinus, AEA ante-
LP lamina papyracea rior ethmoid artery

2. Rajapaksa SP, Ananda A, Cain T, Oates L, Wormald PJ.  Frontal

12.6 Postoperative Tips ostium neo-osteogenesis and restenosis after modified endoscopic
Lothrop procedure in an animal model. Clin Otolaryngol Allied Sci.
After surgery, patients are requested to clean their nose with 2004;29(4):386–8.
saline plus xylitol four to six times a day. The patient is 3. Hilding AC, Banovetz J. Occluding scars in the sinuses: relation to
bone growth. Laryngoscope. 1963;73:1201–18.
checked after 1 week to remove the remaining absorbable 4. Schaefer SD, Close LG. Endoscopic management of frontal sinus
hemostat dressing, fibrin, and blood clots. Curved suctions disease. Laryngoscope. 1990;100(2):155–60.
are used under local anesthesia to clean the newly created 5. Hosemann W, Kuehnel T, Held P, Wagner W, Felderhoff

sinus ostium and prevent undesirable displacement of the A. Endonasal frontal sinusotomy in surgical management of chronic
sinusitis: a critical evaluation. Am J Rhinol. 1997;11:1–9.
mucosal grafts. After cleansing with gentle saline irrigation, 6. Hosemann W, Weber R, Keerl R, Lund V. Minimally invasive endo-
the authors cover the cavity with antibiotic cream. nasal sinus surgery. Stuttgart: Thieme; 2000. p. 54–9.
Postoperative debridements are scheduled every week for 1 7. Van Alyea OE. Frontal sinus drainage. Ann Otol Rhinol Laryngol.
month after the operation. 1939;55:267–77.
8. Kasper KA.  Nasofrontal connections-a study based in a one hun-
dred consecutive dissections. Arch Otolaryngol. 1936;23:322–43.
9. Wormald PJ.  Surgical approach to the frontal sinus and frontal
References recess. In: Endoscopic sinus surgery. Anatomy, three-dimensional
reconstruction and surgical technique. 3rd ed. New York: Springer;
1. Rajapaksa SP, Ananda A, Cain T, Oates L, Wormald PJ. The effect 2013. p. 91–3.
of the modified endoscopic Lothrop procedure on the mucociliary
clearance of the frontal sinus in an animal model. Am J Rhinol.
2004;18(3):183–7.
 Bone Removal Grade 5 (Complete
Removal of Unilateral Frontal Sinus 13
Floor) Including Eloy IIC, IID, IIE, IIF

Christina H. Fang, Ariel Omiunu, Jordon G. Grube,

and Jean Anderson Eloy

13.1 Introduction successful surgical intervention and improvement of long-­

term outcomes.
Endoscopic frontal sinus surgery is commonly performed for There are several surgical approaches described in the lit-
various frontal sinus pathologies, including recalcitrant erature for management of frontal sinus disease. The stan-
chronic frontal sinusitis, frontal sinus mucoceles, and neo- dard endoscopic approaches include the Draf I (Eloy I), Draf
plasms [1]. The advent of endoscopic frontal sinus surgery IIA (Eloy IIA), Draf IIB (Eloy IIB), and Draf III (Eloy III)
has enabled the stepwise progression from open destructive procedure. In the Draf I (Eloy I) procedure, the anterosupe-
techniques to minimally invasive endonasal approaches, rior ethmoidal cells, including the agger nasi are resected
reducing the burden of postoperative care and recovery [2]. without manipulation of the frontal sinus outflow tract
However, endoscopic frontal sinus surgery still proposes (Fig.  13.1a). The Draf IIA (Eloy IIA) procedure involves
technical challenges to surgeons, owing to the considerable removal of the anterior ethmoid cells and frontal cells
anatomic variation of the frontal sinus drainage pathway, as between the middle turbinate medially and the lamina papy-
well as its proximity to vital structures [3, 4]. These chal- racea laterally (Fig. 13.1b). The Draf IIB (Eloy IIB) proce-
lenges create the potential for surgical failure, including dure further enlarges the frontal sinus drainage pathway by
incomplete surgery, which can lead to recurrent or persistent including removal of the frontal sinus floor between the nasal
frontal sinus disease, postoperative stenosis, or iatrogenic septum and lamina papyracea and resection of the anterior
injury [5, 6]. Therefore, continued advances in frontal sinus superior head of the middle turbinate (Fig.  13.1c). When
operative techniques and instrumentation are essential for these procedures fail, the endoscopic modified Lothrop pro-
cedure (EMLP), also known as the frontal sinus drill-out or
Draf III (Eloy III) procedure, can be performed (Fig. 13.1d).
The Lothrop procedure, originally described in 1914, was
C. H. Fang · A. Omiunu
Department of Otolaryngology – Head and Neck Surgery,
designed to enlarge and combine the nasofrontal drainage
Rutgers New Jersey Medical School, pathways in patients with recalcitrant frontal sinusitis [7]. It
Newark, NJ, USA was initially performed via an external frontal-­ethmoidectomy
J. G. Grube approach, with resection of the medial frontal sinus floor,
Department of Otolaryngology – Head and Neck Surgery, superior nasal septum, and intersinus frontal septum. In the
Albany Medical Center, Albany, NY, USA following years, advances in endoscopic technology have
J. A. Eloy (*) allowed for modifications of Lothrop's open technique.
Department of Otolaryngology – Head and Neck Surgery, Rutgers Several surgeons, including Draf [8] in 1991, Close et al. [9]
New Jersey Medical School, Newark, NJ, USA
in 1994, and Gross et al. [10] in 1995, described the original
Center for Skull Base and Pituitary Surgery, Neurological Institute procedure performed entirely through an advanced endo-
of New Jersey, Rutgers New Jersey Medical School,
Newark, NJ, USA
scopic endonasal approach. The EMLP or Draf III (Eloy III)
procedure similarly involves removal of the frontal sinus
Department of Neurological Surgery, Rutgers New Jersey Medical
School, Newark, NJ, USA
floor anterior to the middle turbinates between the bilateral
lamina papyracea with a superior septectomy and intersinus
Department of Ophthalmology and Visual Science, Rutgers New
Jersey Medical School, Newark, NJ, USA
septectomy, thereby creating a contiguous frontal sinus
drainage pathway.
Department of Otolaryngology and Facial Plastic Surgery, Saint
Barnabas Medical Center - RWJBarnabas Health,
In some cases, the Draf III (Eloy III) procedure may
Livingston, NJ, USA involve unnecessary resection of structures surrounding the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 165
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_13
166 C. H. Fang et al.

a b

c d

Fig. 13.1  Artwork of the paranasal sinuses in the coronal plan depicting the (a) Draf I (Eloy I), (b) Draf IIA (Eloy IIA), (c) Draf IIB (Eloy IIB),
and (d) Draf III (Eloy III) procedures (© 2015 Chris Gralapp, Fairfax, CA)

frontal recess and frontonasal duct [11]. Typically, less regions, and to preserve frontal sinus anatomy. The MHLP
extensive approaches to the frontal sinuses are considered, as (Eloy IIC) is indicated in patients with unilateral, laterally
surgical manipulation in the frontal sinus recess can increase based frontal sinus disease. The superior septectomy in the
the risk of postoperative osteoneogenesis and stenosis. More MHLP allows for binostril bimanual instrumentation, thus
recent and less invasive variations of the Draf III (Eloy III) improving surgical maneuverability. The MMLP (Eloy
procedure, notably the modified hemi-Lothrop procedure IID) is intended to treat disease in patients with an ipsilat-
(MHLP) (Eloy IIC) [12–15] (Fig. 13.2), the modified mini-­ eral inaccessible frontal sinus recess. Because of underly-
Lothrop procedure (MMLP) (Eloy IID) [16, 17] (Fig. 13.3), ing pathology, such as trauma or scarring, resection of the
the modified subtotal-Lothrop procedure (MSLP) (Eloy IIE) ipsilateral frontal sinus floor cannot be achieved using tra-
[18, 19] (Fig. 13.4), and the modified central-Lothrop proce- ditional endoscopic techniques. Use of the MMLP may be
dure (MCLP) (Eloy IIF) [20] (Fig.  13.5) have been estab- an alternative to more extensive procedures, including
lished in efforts to preserve as much of the native sinonasal external frontal sinus approaches or the EMLP [22]. The
architecture as feasible and to prevent postoperative scarring MSLP (Eloy IIE) is used to provide exposure for access to
and failure [21]. bilateral posterior frontal sinus tables for large unilateral
frontal sinus or anterior skull base lesions with preserva-
tion of the contralateral non-­diseased frontal sinus recess
13.2 Indications [18]. This approach can also be used for large posterior
frontal sinus table encephaloceles [19]. The MCLP (Eloy
The aforementioned modified endoscopic techniques were IIF) is used in patients with frontal sinus disease located
designed to address areas of the frontal sinus that are dif- near the midline nasal region who do not want an external
ficult to access, such as the lateral recess and supraorbital incision.
13  Bone Removal Grade 5 (Complete Removal of Unilateral Frontal Sinus Floor) Including Eloy IIC, IID, IIE, IIF 167

a b

Fig. 13.2 (a) Artwork of the paranasal sinuses in the coronal plane arrow depicts improvement in lateral reach through the contralateral
depicting the approach to the contralateral frontal sinus using the Eloy nostril through the superior septectomy window. This approach allows
IIC procedure, also known as the modified hemi-Lothrop procedure. binostril instrumentation through the left nostril (b) and right nostril (c)
Dotted line depicts location of the superior septectomy. Red arrow (© 2015 Chris Gralapp, Fairfax, CA)
depicts limited lateral reach through the ipsilateral left nostril. The blue

13.3 Preoperative Tips surgery [23]. These include the attachment of the uncinate
process, frontal sinus asymmetry, frontal sinus pneumati-
• It is important to understand the set of circumstances in zation, lamina papyracea dehiscence, location of the ante-
which each surgical approach to the frontal sinus can and rior ethmoidal artery, presence of nasoethmoid cells
should be used. (agger nasi, suprabullar, supraorbital, frontal cells), and
• Adequate understanding of the limitations of each of presence of osteoneogenesis.
these frontal sinus procedures and its indications is para- • Using bimanual instrumentation can help with a more
mount for successful outcomes. controlled dissection.
• There is usually more than one surgical technique or • If significant drilling is undertaken, care should be taken
approach for a given pathologic frontal sinus condition. to prevent circumferential bone exposure to prevent
Clear and open discussion with the patient about the pre- stenosis.
ferred approach and likelihood of success is important • Limited drilling with a small frontal sinus exposure/open-
before any frontal sinus procedure. ing is likely to result in failure.
• Anatomic sinonasal variations should be examined on • Image guidance, although not essential, can be useful in
preoperative imaging prior to endoscopic frontal sinus patients with difficult anatomy.
168 C. H. Fang et al.

a b

Fig. 13.3 (a) Artwork of the paranasal sinuses in the coronal plane frontal sinusotomy (red arrow). (b) Following a frontal intersinus sep-
depicting the Eloy IID procedure, also known as the modified mini-­ tectomy, drainage of the frontal sinus via the contralateral nasal cavity
Lothrop procedure. In this example, fat prolapse prevents an ipsilateral is achieved (© 2015 Chris Gralapp, Fairfax, CA)

Fig. 13.5  Artwork of the paranasal sinuses in the coronal plane show-
Fig. 13.4  Artwork of the paranasal sinuses in the coronal plane show-
ing bilateral frontal sinus access with the Eloy IIF (modified central-­
ing bilateral frontal sinus access with the Eloy IIE (modified subtotal-­
Lothrop procedure) with preservation of bilateral frontal sinus recesses
Lothrop procedure) with preservation of the contralateral frontal sinus
(© 2015 Chris Gralapp, Fairfax, CA)
recess (© 2015 Chris Gralapp, Fairfax, CA)

• Although the MHLP allows for significant surgical mobil-

13.4 Pearls and Potential Pitfalls ity and binostril instrumentation, the preservation of the
frontal sinus intersinus septum prevents access to the con-
• Careful analysis of preoperative imaging should be per- tralateral frontal sinus and would be limited for lesions
formed to determine which modification would be most that approach or cross the midline [12, 13, 15].
appropriate for treatment of the patient’s specific pathol- • In the MMLP, a technical concern to consider is the abil-
ogy [24]. ity to perform the intersinus septectomy through the Draf
• The least invasive approach is ideal in many cases, as IIB opening. In cases where the anatomy requires greater
preservation of the uninvolved frontal sinus recess pre- surgical maneuverability for instrumentation, a limited
serves mucociliary clearance of the recess. The selected superior septectomy may need to be performed in addi-
approach should, however, provide adequate exposure tion to the intersinus septectomy. This still provides a
and surgical maneuverability to achieve complete resec- more limited dissection than the traditional EMLP and
tion of disease. decreased morbidity for the patient [17].
13  Bone Removal Grade 5 (Complete Removal of Unilateral Frontal Sinus Floor) Including Eloy IIC, IID, IIE, IIF 169

13.5 Surgical Procedure and Schematic dure with identification of the ipsilateral frontal recess and
Descriptions frontal sinus ostium. The floor of the frontal sinus and naso-
frontal beak is subsequently resected with powered instru-
13.5.1 Modified Hemi-Lothrop Procedure/Eloy mentation. As much bone as possible is removed anteriorly
IIC (Fig. 13.2) from the nasofrontal beak to provide as large a frontal sinus
recess opening as allowed anatomically. This is followed by
The endoscopic MHLP is a technique used to improve access an endoscopic superior septectomy and frontal intersinus
to the unilaterally diseased frontal sinus. The procedure septectomy. Access to the ipsilateral and medial contralateral
begins with an ipsilateral Draf IIB procedure, described as frontal sinus is then achieved. This technique allows for
the removal of the frontal sinus floor from the nasal septum binostril bimanual instrumentation and much improved lat-
medially to the lamina papyracea laterally [8]. A superior eral access through the superior septotomy window from the
septectomy is then performed, creating a window through contralateral nasal cavity.
which to pass an endoscope and instruments from the contra-
lateral nasal cavity. The MHLP enhances access to the lateral
supraorbital frontal sinus and supraorbital ethmoid regions 13.5.4 Modified Central-Lothrop Procedure/
with preservation of the contralateral non-diseased frontal Eloy IIF (Fig. 13.5)
sinus recess. In addition, it provides surgical freedom by
allowing bimanual, binostril instrumentation through the The MCLP involves bilateral removal of the medial frontal
contralateral nasal cavity. sinus floor with a superior septectomy and frontal intersinus
septectomy [20]. There is preservation of the bilateral frontal
sinus recesses. Access to and visualization of both frontal
13.5.2 Modified Mini-Lothrop Procedure/Eloy sinuses are achieved through this central opening, which
IID (Fig. 13.3) allows for binostril and bimanual instrumentation. Although
this modification may result in scarring and subsequent
The MMLP allows drainage of an inaccessible or obstructed obstruction of the central opening, both frontal sinus recesses
ipsilateral frontal sinus recess, which can occur from prior remain untouched. The resection of the frontal intersinus
iatrogenic or traumatic scarring, frontal recess stenosis, septum or any frontal sinus partition allows for adequate
tumor, osteoneogenesis, or prior medial orbital wall decom- communication between the two sides with a drainage path-
pression [20]. The MMLP begins with a standard Draf IIB way through either recess should stenosis of the central
procedure on the contralateral, non-diseased frontal sinus. opening occur.
An endoscopic frontal intersinus septectomy is then per-
formed, which establishes access to the diseased frontal
sinus and allows for drainage through the non-diseased fron- 13.6 Postoperative Tips
tal sinus recess. While a complete intersinus septectomy is
not required for the EMLP (because of the opening of both Like the EMLP, the surgical modifications described in this
recesses), a total or near-total intersinus septectomy is desir- chapter can also create a large area of bare bone in the frontal
able in the MMLP, as this opening becomes the only drain- sinuses. Osteitis can develop from the exposed bone and acts
age pathway for the diseased frontal sinus [16]. This as a source of inflammation causing local mucosal edema,
modification allows access to both posterior frontal sinus frontal ostia narrowing, and ultimately surgical failure [25].
tables, but has limited surgical freedom due to mononostril In meta-analyses of the EMLP, the failure rate has been
access. found to be 13.9–17.1% [26, 27]. Similar methods used to
prevent postoperative stenosis following the EMLP can be
applied to these modifications. Specifically, care should be
13.5.3 Modified Subtotal-Lothrop Procedure/ taken to maximize the size of the frontal recess, to remove all
Eloy IIE (Fig. 13.4) osteitic bone, to prevent circumferential mucosal trauma,
and to use powered instrumentation judiciously [17]. In
The MSLP has the advantages of allowing exposure of the addition, the use of mucosal grafts, pedicled flaps, or syn-
anterior skull base in cases where lesions are present unilat- thetic materials, such as a silastic sheet to cover the exposed
erally, providing simultaneous access to the ipsilateral far bone of the nasofrontal beak has been shown to improve the
lateral and contralateral medial segments of the pathologic rate of postoperative stenosis [28]. Establishment of a well-­
frontal sinus, and preserving one frontal sinus recess [18]. mucosalized frontal outflow tract interrupts the geography of
The MSLP begins with a standard unilateral Draf IIB proce- a circumferential scar, thereby preventing stenosis [28]. Free
170 C. H. Fang et al.

mucosal grafts can be taken from the superior septectomy 13. Eloy JA, Kuperan AB, Friedel ME, Choudhry OJ, Liu JK. Modified
hemi-Lothrop procedure for supraorbital frontal sinus access: a
site, inferior turbinate, or nasal cavity floor. These grafts are
case series. Otolaryngol Head Neck Surg. 2012;147(1):167–9.
then bolstered by stents, such as corticosteroid-eluting stents 14. Liu JK, Mendelson ZS, Dubal PM, Mirani N, Eloy JA. The modi-
(Propel, Intersect ENT, Menlo Park, CA) to allow for ade- fied hemi-Lothrop procedure: a variation of the endoscopic endo-
quate imbibition and to provide a barrier to desiccation. nasal approach for resection of a supraorbital psammomatoid
ossifying fibroma. J Clin Neurosci. 2014;21(12):2233–8.
15. Friedel ME, Li S, Langer PD, Liu JK, Eloy JA.  Modified hemi-­
Financial Disclosures None Lothrop procedure for supraorbital ethmoid lesion access.
Laryngoscope. 2012;122(2):442–4.
Conflicts of Interest None 16. Eloy JA, Friedel ME, Kuperan AB, Govindaraj S, Folbe AJ, Liu
JK.  Modified mini-Lothrop/extended Draf IIB procedure for
contralateral frontal sinus disease: a cadaveric feasibility study.
Otolaryngol Head Neck Surg. 2012;146(1):165–8.
References 17. Eloy JA, Friedel ME, Kuperan AB, Govindaraj S, Folbe AJ, Liu
JK. Modified mini-Lothrop/extended Draf IIB procedure for con-
1. Eloy J, Setzen M.  Frontal sinus disease: contemporary manage- tralateral frontal sinus disease: a case series. Int Forum Allergy
ment, vol. 49. Amsterdam: Elsevier; 2016. Rhinol. 2012;2(4):321–4.
2. Korban ZR, Casiano RR. Standard endoscopic approaches in frontal 18. Eloy JA, Liu JK, Choudhry OJ, et al. Modified subtotal lothrop pro-
sinus surgery: technical pearls and approach selection. Otolaryngol cedure for extended frontal sinus and anterior skull base access: a
Clin N Am. 2016;49(4):989–1006. cadaveric feasibility study with clinical correlates. J Neurol Surg B
3. Nakagawa T, Ito J.  Endoscopic modified Lothrop procedure Skull Base. 2013;74(3):130–5.
for postoperative frontal mucocele. Acta Otolaryngol Suppl. 19. Eloy JA, Mady LJ, Kanumuri VV, Svider PF, Liu JK.  Modified
2007;557:51–4. subtotal-Lothrop procedure for extended frontal sinus and ante-
4. Sonnenburg RE, Senior BA.  Revision endoscopic fron- rior skull-base access: a case series. Int Forum Allergy Rhinol.
tal sinus surgery. Curr Opin Otolaryngol Head Neck Surg. 2014;4(6):517–21.
2004;12(1):49–52. 20. Eloy JA, Vazquez A, Liu JK, Baredes S. Endoscopic approaches to
5. Valdes CJ, Bogado M, Samaha M. Causes of failure in endoscopic the frontal sinus: modifications of the existing techniques and pro-
frontal sinus surgery in chronic rhinosinusitis patients. Int Forum posed classification. Otolaryngol Clin N Am. 2016;49(4):1007–18.
Allergy Rhinol. 2014;4(6):502–6. 21. Eloy JA, Marchiano E, Vazquez A. Extended endoscopic and open
6. Nakayama T, Asaka D, Kuboki A, Okushi T, Kojima H. Impact sinus surgery for refractory chronic rhinosinusitis. Otolaryngol Clin
of residual frontal recess cells on frontal sinusitis after N Am. 2017;50(1):165–82.
endoscopic sinus surgery. Eur Arch Otorhinolaryngol. 22. Close LG. Endoscopic Lothrop procedure: when should it be con-
2018;275(7):1795–801. sidered? Curr Opin Otolaryngol Head Neck Surg. 2005;13(1):67–9.
7. Nayak DR, Pai K, Nair S, Ramaswamy B, Sabhahit H. A short term 23. Eloy JA, Svider PF, Setzen M.  Preventing and managing com-
subjective and objective analysis of modified endoscopic Lothrop’s plications in frontal sinus surgery. Otolaryngol Clin N Am.
procedure and its functional outcome: our experience. Indian J 2016;49(4):951–64.
Otolaryngol Head Neck Surg. 2016;68(4):481–6. 24. Eloy JA, Svider PF, Setzen M. Clinical pearls in endoscopic sinus
8. Draf W.  Endonasal micro-endoscopic frontal sinus surgery: the surgery: key steps in preventing and dealing with complications.
fulda concept. Oper Tech Otolaryngol. 1991;2(4):234–40. Am J Otolaryngol. 2014;35(3):324–8.
9. Close LG, Lee NK, Leach JL, Manning SC. Endoscopic resection 25. Lee JT, Kennedy DW, Palmer JN, Feldman M, Chiu AG. The inci-
of the intranasal frontal sinus floor. Ann Otol Rhinol Laryngol. dence of concurrent osteitis in patients with chronic rhinosinusitis:
1994;103(12):952–8. a clinicopathological study. Am J Rhinol. 2006;20(3):278–82.
10. Gross WE, Gross CW, Becker D, Moore D, Phillips D. Modified 26. Anderson P, Sindwani R.  Safety and efficacy of the endoscopic
transnasal endoscopic Lothrop procedure as an alternative to frontal modified Lothrop procedure: a systematic review and meta-­
sinus obliteration. Otolaryngology. 1995;113(4):427–34. analysis. Laryngoscope. 2009;119(9):1828–33.
11. Jafari A, Tringale KR, Panuganti BA, Acevedo JR, Pang J, DeConde 27. Abuzeid WM, Vakil M, Lin J, et al. Endoscopic modified Lothrop
AS.  Short-term morbidity after the endoscopic modified Lothrop procedure after failure of primary endoscopic sinus surgery: a
(Draf-III) procedure compared with Draf-IIa. Am J Rhinol Allergy. meta-analysis. Int Forum Allergy Rhinol. 2018;8(5):605–13.
2017;31(4):265–70. 28. Wang YP, Shen PH, Hsieh LC, Wormald PJ. Free mucosal grafts
12. Eloy JA, Friedel ME, Murray KP, Liu JK. Modified hemi-Lothrop and anterior pedicled flaps to prevent ostium restenosis after endo-
procedure for supraorbital frontal sinus access: a cadaveric feasibil- scopic modified Lothrop (frontal drillout) procedure: a randomized,
ity study. Otolaryngol Head Neck Surg. 2011;145(3):489–93. controlled study. Int Forum Allergy Rhinol. 2019;9(11):1387–94.
 Bone Removal. Grade 6: Draf III
14
Alfredo García-Fernández, Nieves Mata-Castro,
and Esther García-González

14.1 Introduction can now be considered the technique of choice in severe

frontal sinus disease.
Endoscopic removal of the floor of both frontal sinuses has
been performed with increasing frequency since 1991 when
it was described by W. Draf [1], under the name of endonasal 14.2 Indications
median drainage or type III sinusotomy. Given its parallel-
ism with the technique described by Lothrop in 1899 [2] Initially, endoscopic frontal sinus drill-out was performed
from which only the approach used distinguishes it, it soon exclusively in inflammatory conditions, but as its use
began to be called endoscopic modified Lothrop procedure became popular, its indications were extended to cover a
(EMLP) [3] or frontal drill-out. Although W.  Draf used to wide range of diseases, including inverted papillomas, cere-
perform the procedure combining the use of the microscope brospinal fluid (CSF) leaks, frontal sinus fractures, failed
with that of the endoscope, nowadays practically all sur- frontal sinus obliteration, or mucocele. Subsequent studies
geons use the latter exclusively. describing its efficacy in the surgical treatment of recalci-
The technique consists of removing the floor of the frontal trant nasal polyposis have provided a high number of
sinus located between the two orbital walls, together with as patients who are candidates for its use [5–7]. It is also con-
much interfrontal septum as possible, and the adjacent por- sidered essential as a previous step to endoscopic craniofa-
tion of the nasal septum, thereby creating a large single fron- cial resection; furthermore, it allows surgeons to use the
tonasal drainage pathway. frontal sinus to transpose the pericranial flap into the nasal
Due to its technical difficulty and proximity to both the cavity [8, 9] (see Chap. 15).
orbit and base of the skull, this intervention was deemed dan-
gerous for many years. However, advances in anatomical
knowledge, an increase in the experience gained by sur- 14.3 Anatomy
geons, the development of adequate instruments, and the use
of navigation systems have gradually facilitated its wide- The anatomical area in which the surgery is performed pri-
spread use [4]. Therefore, endoscopic frontal sinus drill-out marily consists of a bone complex composed of the floor of
the frontal bone with its midline prominence or nasofrontal
beak, the frontal processes of the maxillae, and the most pos-
A. García-Fernández (*)
Department of Otorhinolaryngology-Head and Neck Surgery, terior portion of the nasal bones (Fig. 14.1). It relates anteri-
University Hospital 12 de Octubre, Madrid, Spain orly to the skin of the nasion, laterally to the orbits, and
Department of Otorhinolaryngology-Head and Neck Surgery, posteriorly to the ostium of the frontal sinus laterally and to
Hospital Puerta del Sur, Móstoles, Spain the cribriform plate and crista galli medially.
N. Mata-Castro The beak is often pneumatized by anterior ethmoid cells,
Department of Otorhinolaryngology-Head and Neck Surgery, thereby facilitating its resection.
Hospital Puerta del Sur, Móstoles, Spain The most feared complication of Draf III is the CSF leak.
Department of Otorhinolaryngology-Head and Neck Surgery, Avoiding this complication requires accurate determination
Hospital de Torrejón, Madrid, Spain of the location of the cribriform plate. Although navigation
e-mail: [email protected]
systems have facilitated this, knowledge of anatomical land-
E. García-González marks is essential to accurately identify boundaries.
Department of Otorhinolaryngology-Head and Neck Surgery,
University Hospital 12 de Octubre, Madrid, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 171
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_14
172 A. García-Fernández et al.

Fig. 14.1  MPR reconstruction showing the different bone components to be removed in the DRAF IIII procedure. MPR multiplanar
reconstruction

Fig. 14.2  Right fossa. S septum, B beak, MD middle turbinate Fig. 14.3  Right fossa. S septum, B beak, MD middle turbinate, G arte-
rial groove, OF first olfactory fiber

The most commonly used landmark is the first olfactory

nerve, theoretically located in the most anterior portion of About 3 mm anteriorly to the first olfactory nerve, through
the cribriform plate. This nerve emerges in the space between the criboethmoidal foramen located in the most anterior mar-
the middle turbinate and the septum, posteriorly to the inser- gin of the cribriform plate, in a lateral location within the
tion of the middle turbinate at the base of the skull, at a vari- olfactory cleft, the nasal branch of the anterior ethmoidal
able distance from it. artery exits from the base of the skull [11]. Initially, it runs
Although the first olfactory nerve has been considered a along the inferior aspect of the beak, carving in it an approxi-
reliable landmark for locating the anterior margin of the crib- mately 3-mm-long longitudinal groove on its way to the nasal
riform plate, studies have shown that it is located up to 6 to dorsum (Figs. 14.2 and 14.3). This groove, present in 95% of
7 mm behind it [10]. cases [11], is characteristic of the origin of the artery and
14  Bone Removal. Grade 6: Draf III 173

makes it possible to differentiate it from the circular orifice space can be solved by using Kerrison Rongeurs or by
through which the olfactory nerve emerges. This is important front-to-back drilling.
because while drilling the bone at the level of the artery sul- • The depth of the largest anteroposterior portion of the
cus leads to the frontal sinus, doing it at the level of the nerve frontal sinus, just above the ostium, should reach 7 mm,
leads to the anterior cranial fossa and the creation of a CSF according to some authors [13].
leak.
The anterior portion of the cribriform plate is always in a In any case, the feasibility of performing Draf III largely
coronal plane posterior to that of the anterior margin of the depends on the surgeon’s experience, and most of the limita-
frontal ostium. For this reason, the beak has been proposed tions suggested by the measurements can be overcome by
as a landmark for performing superior septectomy [12]. optimizing the technique.
The anterior border of the cribriform plate is often located
approximately 1  mm anterior to the posterior wall of the
frontal infundibulum [11]. Therefore, its use as a landmark 14.5 Pearls and Potential Pitfalls
should be taken with caution.
The patient must consent to an open approach, if necessary,
especially in oncologic surgery.
14.4 Preoperative Tips The patient must be placed in a supine position, with the
neck slightly hyperextended to facilitate access to the frontal
Depending on the disease, preoperative administration of sinus.
antibiotics and corticosteroids may be indicated to optimize Gauzes with a vasoconstrictor are placed inside the nos-
the surgical field. trils to adequately retract the mucosa.
Although using a navigation system is not essential and When other interventions are to be performed during the
never replaces adequate knowledge of the patient’s anatomy, same surgery, such as polypectomy, ethmoidectomy, or
it should be used in cases of reinterventions, previous trauma, sphenoidectomy, they should be performed before the
or anatomical abnormalities. Even if the navigation system is approach to the frontal sinus.
not going to be used, a high-resolution CT scan should be The entire procedure can usually be performed using the
available for an adequate preoperative three-dimensional 30° endoscope, but in some cases, it may be convenient to
analysis. use the 45° or even the 70° one to visualize the most lateral
Anatomical criteria have been established for the success- areas of the sinus. However, some surgeons use only the 0°
ful performance of a Draf III, some of which are related to one [16]. We consider that if the beak is completely removed,
the technical difficulties in performing the surgery, while the 0° optic allows the anterior wall of the frontal sinus to be
others are prognostic indicators of the long-term patency of seen, which is an indicator of the quality of the procedure.
the osteotomy [13–15]. Some of them are as follows: Angle drills and Kerrison Rongeurs with upwards and down-
In the midsagittal plane: wards bites should be added to the usual material in any
ethmoidectomy.
• The thickness of the beak, which some authors have lim- As a general rule, surgery should be as atraumatic as pos-
ited to 1 cm due to technical difficulties in drilling thicker sible, preserving as much mucosa as possible, especially in
bones. In many patients, the beak is pneumatized, which the frontal recess.
notably facilitates its removal.
• The distance from the nasion to the base of the skull,
which indicates the maximum anteroposterior diameter of 14.6 Surgical Technique
the sinusotomy that can be performed and which should
not be less than 1.5 cm, according to some authors. Although the sequence of surgical steps depends on the sur-
geon’s preferences, we recommend following the next one.
In the parasagittal plane, crossing the middle of the fron- This technique has been designed in a logical order, with
tal sinus ostium, the following criteria are considered: each step facilitating the performance of the next.

• The accessible dimension, which is the distance from the

anterior margin of the frontal ostium to the base of the 14.6.1 Location of the Anterior Margin
skull, has been established at a minimum of 5 mm, con- of the Cribriform Plate
sidering that this is the minimum space necessary to
safely introduce a drill. However, nowadays, the drills are Using a Colorado needle, an arched incision is made that
getting increasingly smaller, and the problem of the small runs through the axilla of the middle turbinate, crosses the
174 A. García-Fernández et al.

roof of the nasal cavity, and descends through the septum. 14.6.4 Frontal Floor Resection
The mucosa is detached in the subperiosteal plane until the
characteristic groove of the nasal branch of the anterior eth- The frontal floor has a highly variable thickness and is some-
moidal artery is identified, which marks the posterior margin times pneumatized, which facilitates its resection. Below the
of the bone removal. The branch of the olfactory nerve, pos- frontal floor, the ascending processes of the maxilla must be
terior and medial to the artery, should be identified only in thinned as much as possible by drilling in order to ensure
case of doubt. maximum lateral opening.
The frontal floor can be removed using Kerrison Rongeurs
or angle drills connected to high-speed motors. Our prefer-
14.6.2 Identification of the Frontal Sinus ence is to start the resection with Kerrison Rongeurs,
Ostium although the thickness of the beak sometimes requires using
the drill from the outset. We begin by resecting the axilla of
The frontal sinus ostium must be exposed, at least unilater- the middle turbinate ipsilaterally from both fossae until we
ally, and, if possible, on both sides. The technique used to are clearly in front of the cribriform plate (Figs.  14.5 and
expose the frontal sinus ostium, Draf I, is beyond the scope 14.6). Then, we can start to medialize the resection until both
of this chapter (see Chap. 10). sides are connected, which is facilitated by introducing the
Kerrison Rongeurs through the contralateral nasal cavity. If
Kerrison Rongeurs handle comes into contact with the
14.6.3 Septectomy patient’s chest and prevents its use, Kerrison Rongeurs with
down bite can be used with the handle facing up.
Ideally, the posterior septectomy incision should be made at Once both sides are connected, the opening must be
the level of the first olfactory nerve, descending until approx- enlarged by drilling both laterally and in the forward direc-
imately half of the middle turbinate, and be carried forward tion. Some surgeons recommend reaching the periosteum in
by approximately 2 cm. This incision can be modified to pre- both directions to ensure that the space is maximized. In our
serve the pedicled mucosa and be used as a flap, even bilater- experience, periosteum exposure significantly increases
ally. The underlying cartilage and bone are then resected to postoperative discomfort; therefore, we prefer to drill the
complete the septectomy. Its size should allow direct access maxillary process until it is in the same plane as the lamina
from each fossa to the contralateral frontal recess. papyracea and drill the beak anteriorly until it is in the same
Simultaneously, the root of the middle turbinate must be plane as the anterior wall of the frontal bone. The interfrontal
resected until it is in the same coronal plane as the posterior septum is resected as much as possible vertically, albeit with-
margin of the septectomy (Fig. 14.4). out requiring full removal.

Fig. 14.4  After performing DRAF IIA, the anatomical relationship Fig. 14.5  Bone removal progresses medially several millimeters in
between the arterial groove, the first olfactory nerve, the frontal sinus front of the nerve to avoid damage of the cribriform plate (CP). CP
and the cribriform plate becomes evident. G arterial groove, OF first cribriform plate, FS frontal sinus
olfactory fiber, FS frontal sinus, B beak
14  Bone Removal. Grade 6: Draf III 175

Fig. 14.7  Intraoperative video capture of a Draf III

Fig. 14.6  Final steps of the Draf III procedure. When combined with
an ethmoidectomy, the thin bone lamellas between the frontal sinus and
the anterior ethmoid must be removed. S septum, MD middle turbinate,
FS frontal sinus

14.6.5 Posterior Enlargement

Posterior enlargement consists of maximizing the anteropos-

terior diameter of the sinusotomy at the expense of the pos-
terior bone margin, avoiding injury to the cribriform plate
and causing a CSF leak. For this purpose, a diamond drill is
used to drill the posterior floor of the frontal sinus until
reaching the anterior margin of the cribriform plate. This will
form the image of a T with the posterior margin of the sep-
tectomy, the so-called T of Draf (Fig. 14.7) [17].
Careful hemostasis is performed, paying special attention
to the anterior edge of the septectomy. Subsequently, either
the surgery has ended, or free or pedicled mucosa flaps are
placed on the denuded bone.
When the procedure is performed to treat inflammatory
disease, especially if the patient presents with significant Fig. 14.8  When the inflammatory load is high, we place a silastic sheet
eosinophilia, we place a silastic sheet inside the sinusotomy inside the sinusotomy, to prevent the formation of synechiae
to prevent the formation of adhesions during the epitheliali-
zation process (Fig. 14.8). We also place silastic splints on
both sides of the septum to avoid synechiae and perform Previously, it was necessary to locate the cribriform plate
bilateral packing. and perform a septectomy as in the classic procedure. The
beak is then drilled from front to back, and finally, the recess
bone is removed with Kerrison Rongeurs. Since the sinus is
14.6.6 Outside-in blindly accessed and the anterior wall of the sinus is not vis-
ible, the external periosteum should be exposed to determine
The procedure can also be performed by starting the drilling the anterolateral margins of the drilling.
in the anterior area and moving towards the recesses, in the Besides the personal preferences of each surgeon, the
opposite direction to that of the classical technique [16]. advantages of the outside-in approach include avoiding the
176 A. García-Fernández et al.

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anterior ethmoid cells. Ann Surg. 1899;29:172–215.
3. Close LG, Lee NK, Leach JL, et  al. Endoscopic resection of
the intranasal frontal sinus floor. Ann Otol Rhinol Laryngol.
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4. Shih LC, Patel VS, Choby GW, Nakayama T, Hwang PH. Evolution
of the endoscopic modified Lothrop procedure: a systematic review
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7. Morrissey DK, Bassiouni A, Psaltis AJ, Naidoo Y, Wormald
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consistent landmark for a midline approach to the frontal sinus. Int
serving their integrity if they are not affected by the disease.
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References otot.2006.03.002.

1. Draf W.  Endonasal micro-endoscopic frontal sinus surgery: the

Fulda concept. Operat Techniq Otolaryngol Head Neck Surg.
1991;2(4):234–40.
 Frontal Sinus Surgery (Draf III)
as a Previous Step to a more Complex 15
Technique Part 1

Juan Carlos Ceballos Cantu, Isam Alobid Alobid,
and Cristóbal Langdon Montero

15.1 Introduction
FS
Endoscopic sinus surgery (ESS) has a well-defined role in
the management of the neoplasm of the sinonasal tract. The
vast majority of the lesions, including malignant tumors, can
be adequately managed by this approach; each day the indi-
*
cations expand with encouraging results. The traditional
*
approach for frontal sinus tumors was through an osteoplas- O O
tic flap (OPF), being the gold standard for many years [1]. It
offers great visualization and bimanual instrumentation, but
it is not devoid of morbidity, with potential mucocele forma- >
<
tion, loss of bone flap caused by chronic osteitis, especially PS
if radiotherapy is indicated, and long-term problems such as
frontal deformity or frontal neuralgia [2]. These open
approaches have complication rates between 18 and 60%;
they often involve significant amounts of brain retraction,
neurovascular manipulation, and bad cosmetic results [3, 4].
Endoscopic approach through a Draf III or frontal drillout
has demonstrated that the anterior skull base is accessible in
its full anterior–posterior and lateral extent, ideal for pathol- Fig. 15.1  Extended endonasal approach: transcribriform approach
ogy requiring expanded endonasal approaches (EEA) limits. FS frontal sinus, O orbit, PS planum sphenoidale, *anterior eth-
(Fig. 15.1). Decreased morbidity, no need for sinus oblitera- moidal arteries, >< posterior ethmoidal arteries
tion, significantly better postoperative monitoring, and
improved cosmetic results with the possibility of discharge
from the hospital even on the same day of surgery are some 15.2.1 Osteomas
of the qualities of the endoscopic approach [5].
The grading system described by Chiu et al. [7] proposes a
three-factor guide for decision making regarding appropriate
15.2 Indications and Particular Tumor surgical approach. The size of the osteoma in relation to the
Specifics size of the frontal recess, the point of attachment, and loca-
tion of the lesion in relation to a virtual sagittal plane through
The most common tumors of the frontal sinus and anterior the lamina papyracea. With everyday endoscopic innovation
cranial base are presented in Table 15.1 [6]. and improved instrumentation, this grading system should be
adjusted after recent publications have reported successful
removal of larger tumors even when attached superiorly or
extending laterally to the plane of the lamina papyracea [8].
If the osteoma is too large or lateral, the endoscopic
J. C. C. Cantu (*) · I. A. Alobid · C. L. Montero approach becomes really challenging and time-consuming.
Rhinology and Skull Base Unit, ENT Department, Hospital Clinic,
Osteomas that are pedicled superiorly and out of the reach of
Barcelona, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 177
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_15
178 J. C. C. Cantu et al.

Table 15.1  Most common tumors of the frontal sinus and anterior cra- is performed. A transcribriform approach is generally needed
nial base to manage these tumors, and the limits to this approach are
Benign tumors (Fig. 15.1):
 Osteoma
 Nasal inverted papilloma
• Anteriorly, the posterior wall of the frontal sinuses.
 Fibrous dysplasia
• Laterally, the medial wall of the orbit.
 Meningoceles
 Encephalocele
• Posteriorly, the anterior border of the planum sphenoidale
Malignant tumors at the level of the posterior ethmoidal arteries.
 Squamous cell carcinoma (SCC)
   Sinonasal undifferentiated carcinoma (SNUC)
   Small-cell neuroendocrine carcinomas (SNECs) 15.2.4 Intracranial Malignancies
 Adenocarcinoma
 Esthesioneuroblastoma (ENB) This pathology can be approached endoscopically through a
 Sinonasal non-Hodgkin lymphoma transcribriform approach and can be further expanded with
Intracranial lesions
the additional use of a Draf III or combined approaches
 Sinonasal skull base malignancy with anterior skull base
invasion.
(Fig. 15.2), using the frontal sinus as a corridor into the ante-
 Meningiomas rior fossa [13].
 Olfactory nerve schwannomas However, the increased exposure extending this approach
 Neuroblastoma with a Draf III comes at a cost. This can be time-consuming
 Other intracranial tumors that require transcribriform approach and significantly increases the risk of postoperative CSF
leak. A carefully anatomical and radiological preoperative
study must be done to determine the precise limits because
extended frontal sinus instruments pose a danger when many lesions that require the Draf III may be better
removal because the lesion is often fractured at the base of its approached by craniotomy, as this may result in the shortest
attachment, and if it is located superiorly in the frontal sinus, distance to the tumor and a safer approach [14].
a resultant CSF leak may appear that sometimes it is difficult Some relative contraindications are a narrow anteroposte-
to repair endoscopically. Actually, an occasional CSF leak rior diameter where it can be difficult for instruments to reach,
has to be anticipated, intentionally looked for and repaired at unless proper equipment and surgical experience allows the
the end of the procedure. surgeon to achieve a bigger opening and a better space for
instrumentation. Otherwise, the external route offers greater
comfort for instrumentalization inside the sinus.
15.2.2 Inverted Papillomas (IPs)

Between 1 and 16% of the IPs originates in the frontal sinus.

A study done in IPs of the frontal sinus showed a malignant FS

transformation in 4.1% and recurrence to be 22.4% and

found that no matter the approach (Draf II, Draf III, osteo-
plastic flap or combined approach) recurrence rate was the
same between the approaches, indicating the ability of the
endoscopic approach in providing a magnified view and to
explore around corners with angled lenses assuring a radical
resection [9, 10].

15.2.3 Malignant Sinonasal Tumors

Important surgical advances have forced an update on the

original oncologic principles of anterior craniofacial
­resection for malignant pathology described by Van Buren
[11]. A couple of meta-analyses [12] found no difference in Fig. 15.2  Esthesioneuroblastoma Kadish C, HYAMS 2 with orbital
involvement. Multiportal approach (transcribriform + orbital exentera-
survival rate between surgical approaches to malignant tion). DRAF 3 allows us to secure clear margins and 4-hand dissection,
tumors. When the tumor has a bilateral extension, a Draf III the figure shows the Kerrison rongeur entering through orbit
15  Frontal Sinus Surgery (Draf III) as a Previous Step to a more Complex Technique Part 1 179

15.3 Preoperative Tips

If a purely endoscopic approach is decided, the surgeon must

be sure to have the equipment and ability to do so, and never
hesitate in changing to an open approach.
Even when choosing a purely endoscopic approach, the
patient must always be informed about the possibility of
switching to a combined approach with an external osteo-
plastic flap; an informed consent must always be signed.
A CT scan image study before surgery is mandatory for
bone involvement assessment (limits of the approach) and
for intracranial pathology. Magnetic resonance image (MRI)
helps to discard brain and soft tissue involvement (orbit,
perineural spread), and sometimes angiography is also nec-
essary when vascular pathology is suspected.
Some authors have established a minimum anterior-to-­
posterior diameter of at least 8–10  mm in order for the
procedure to be technically possible [15]. In our experi-
ence, even in frontal sinus agenesia, it is possible to per-
Fig. 15.3  Anterior limits of Draf III where the frontal beak must be
form frontal drillout for anterior cranial fossa pathology brought down and skin must be reached. The white arrow shows a cau-
without adding any risk to the patient. In this case, success terized subcutaneous vessel
depends much on the available instrumentation (0°, 30°,
45° angled endoscopes, neuronavigation, angled burs,
etc.) added to the surgical team experience. Characteristics • The cauterization of the anterior ethmoidal artery (AEA)
that can make tumor removal difficult are its location, should be done in its middle third.
increased convexity of the posterior wall of the frontal • In the scenario where the periorbital fascia is affected and
sinus, the size of the tumor and a superior attachment, as must be dissected, it should be done at the end of the pro-
those are factors that hamper endoscopic instrumentation, cedure, to avoid the orbital fat obstructing the surgical
limiting the amount of space that is available to manipu- field.
late the tumor [7]. • Sufficient dural exposure should be secured in order to
The recommended settings for the procedure are at least send margins for intraoperative pathology and correct flap
two screens, one for the surgeon and the other for the sur- positioning when closure.
geon’s assistant and/or scrub nurse. It is important to have • When skin is resected, z-plasties, split-thickness skin
straight and angled high-speed burs, 0°, 30°, 45°, and 70° grafting, full-thickness skin grafting, or local flaps should
angled scopes, specific frontal sinus instrumentation, and be harvested.
sometimes intraoperative navigation. As with any other • In patients with poorly pneumatized frontal sinuses, cre-
endoscopic sinus surgery, reverse Trendelenburg, and espe- ating a large frontal sinus ostium becomes difficult as
cially when working in the frontal sinus, the extension of the more bone needs to be removed, resulting in a larger
head to a 10–15-degree angle is recommended to facilitate denuded bone surface and less residual mucosa, with an
access of surgical instruments and endoscopes inside the increased risk of obliteration of the frontal ostium. This is
frontal sinus. why it is important to harvest a free mucosal graft.
• Creating the largest ostium possible in surgery with limits
on the skin and periorbital area, avoiding bare bone being
15.4 Pearls and Potential Pitfalls left, added to the pedicled and free grafts, will help pre-
vent circumferential stenosis and less granuloma forma-
• We must respect as much as possible the lateral wall tion compared to what happens when the bone is left
mucosa because it can serve as a graft at the end of the exposed.
surgery. • Paraffin-based ointments should not be used with nasal
• The frontal beak must be brought down until skin is packing after sinus surgery, especially when there has
reached. It is expected that at the lateral aspect an artery been a lesion involving the orbital wall, as they may cause
usually bleeds, and it should be cauterized. This is a reli- paraffinomas (also known as “sclerosing lipogranulomas”
able indicator that we have reached the skin (Fig. 15.3). or “myospherulosis”) [16].
180 J. C. C. Cantu et al.

• The value of frontal sinus stenting is still a subject of drill will be always anterior to the orbit. Drilling is done only
debate. Complications are common and the need for regu- in a superior and lateral direction without drilling medially
lar follow-up sometimes discourages its use. Still, some as this may cause a CSF leak.
authors report successful results with frontal sinus stent- If the dissection is brought medially before the frontal
ing [17]. sinus is entered, the surgeon is likely to damage the area of
the olfactory fossae and cause a CSF leak, this is why a key
step of this surgery is creating the so-called frontal T.
15.5 Surgical Procedure Step by Step If a CSF leak of the posterior table is created, either by
accident or because of the pathology, repair can be achieved
Mainly when approaching tumoral pathology through a Draf by undermining the dural layer subperiosteally in order to
III, two options are available: complete obliteration of the facilitate placement of a multiple underlay fascia lata and
frontal sinus or keeping it open and functional. For the latter, sealing by the normal pressure of the frontal lobe against the
we need to respect the mucosa as much as possible, leave the fistula.
least amount of bone as possible and avoid exposure of denu- When approaching intracranial pathology (transcribri-
dated bone; a wide opening of the sinus floor is key to pre- form approach) the most important vital structures related to
venting stenosis. If we choose to obliterate the frontal sinus, this approach are the orbital content, and the frontopolar and
we should completely remove the mucosa in order to avoid orbitofrontal arteries, branches of the anterior cerebral artery.
mucocele formation. An advantage of this approach is that it allows a two nos-
As Draf III approach has been discussed in another chap- tril and four-hand technique (Fig. 15.4).
ter, we will focus on the special steps when this approach is
used for tumoral pathology and EEA is indicated.
Tumoral pathology usually modifies the anatomy. 15.6 Postoperative Tips
Attention must be paid to identify clear anatomical limits. A
recommended initial step is identifying the posterior limit of It has been described that hospitalization times are decreased
the frontal sinus in order to decrease the risk of injury to the in patients undergoing endoscopic procedures [20]. In the
skull base. Drilling with a burr can become a significant scenario of a complete frontal obliteration, patients are seen
challenge when the tumor completely blocks the frontal in the outpatient clinic after 1 week and then every 2–6 weeks
recess. Tumoral debulking and careful identification of struc- until healing is complete and then tumoral follow-up is done
tures like the lamina papyracea, planum sphenoidale, and the by imaging studies.
frontal beak is necessary to expand our approach until the When the frontal sinus is kept open, postoperative man-
complete frontal sinus is demarcated [18]. agement is crucial for good surgical outcomes. The use of
The removal of the superior part of the nasal septum, the nasal packing depends on the surgeon and surgery.
frontal beak, and the interfrontal septum, hence, the creation
of the largest possible neo-ostium is the main and critical
objective for the success of complete tumor removal and also
for postoperative care and follow-up [19].
Usually, before starting to drill, mucosal flaps are har-
vested or dissected. When treating tumoral pathology,
mucosa must be detached and bone drilled for complete
pathology removal and usually, the frontal sinus is not cov-
ered with grafts, for better postoperative control.
A trans agger approach is recommended especially for O
frontoethmoidal tumors that do not involve the frontal
process of the maxilla because the tumor can be resected
en bloc.
Clear limits on the bony dissection should be obtained.
When turning down the septal mucosa one should find the
nasal branch of the anterior ethmoidal artery as this will be
our posterior limit. Up to that point, we can safely drill with
a diamond bur anteriorly. Anterior and laterally, a small
amount of skin should be exposed, ensuring maximal ostial
width. As long as the exposure of the skin is done directly Fig. 15.4  Sinonasal malignancy resection through a transcribriform
above the axilla of the middle turbinate, the position of the approach using a four-hand technique
15  Frontal Sinus Surgery (Draf III) as a Previous Step to a more Complex Technique Part 1 181

Postoperative courses of oral antibiotics are recommended 10. Walgama E, Ahn C, Batra PS. Surgical management of frontal sinus
inverted papilloma: A systematic review [Internet]. Laryngoscope;
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 Frontal Sinus Surgery (Draf III)
as a Previous Step to More Complex 16
Techniques Part 2

Alfonso Santamaría-Gadea, Cristóbal Langdon,
and Isam Alobid

16.1 Introduction 16.3 Schematic Description

The frontal sinus has classically been approached by external The PCF is made up of the innermost layers of the scalp
approaches such as Lynch and Lothrop [1] procedures, fron- (cranial periosteum and loose connective tissue) and is pedi-
tal osteoplasty, obliteration or cranialization [2, 3]. However, cled to the supraorbital and supratrochlear arteries anteriorly.
from the description of the Draf III approach [4], extended The scalp is composed of five layers [13].
frontal sinusotomy, the complex pathology of the frontal
sinus was no longer limited to open approaches. This tech- • Skin
nique is based on the endoscopic opening of the frontal sinus • Subcutaneous tissue
floor, from orbit to orbit, and the interfrontal septum. • Aponeurotic layer/galeal layer: Connects the frontal and
With the advent of endoscopic surgery and the description occipital muscles. Laterally continuous with the temporo-
of these extended endonasal approaches to the frontal sinus, parietal fascia.
the indications and options for the endoscopic frontal sinus • Loose connective tissue: vascularized tissue that sur-
access have been expanded and the classic limitations greatly rounds a collagen core. This layer facilitates the move-
reduced [5, 6]. In addition to treating the advanced pathology ment of the scalp over the pericranium, which is attached
of the frontal sinus endoscopically, these approaches have to the cranial bone. Continuous with the temporalis fascia
been used as an initial step for other more advanced tech- laterally.
niques. Therefore, the use of the frontal sinus sinusotomy • Pericranium layer: periosteum of the skull bones and in
(Draf III) as a passageway to reconstruct skull base temporal area joins to the deep temporalis fascia, which
approaches, repair cerebrospinal fluid (CSF) leaks, or com- overlies the temporalis muscle.
plete reconstruction of septal perforations with the pericra-
nial flap (PCF) [7–12] has recently been described.
16.3.1 Blood Supply [14, 15]

16.2 Indications The anterior part of the scalp is mainly supplied by the supra-
orbital and supratrochlear arteries (Fig. 16.1). These arteries
Repair of septal perforations. come from the ophthalmic artery, which is a branch of the
Repair of CSF leaks or skull base defects after advanced internal carotid artery. Both arteries enter into the scalp just
endoscopic approaches. above the orbital rim and divide in this area into superficial
To consult other indications of the Draf III approach, see and deep branches. The superficial branches run through the
Chaps. 14 and 15. galea and subcutaneous tissue of the scalp, and the deep
branches pass along the pericranium and the loose areolar
tissue.
A. Santamaría-Gadea (*) The main supply to the PCF comes from the supraorbital
Rhinology and Skull Base Unit, Otorhinolaryngology Department,
artery, which passes through the orbital rim at approximately
Ramón y Cajal University Hospital, Madrid, Spain
30 mm from the midline and divides at this level into super-
C. Langdon · I. Alobid
ficial and deep branches in 80% of cases. The supratrochlear
Rhinology and Skull Base Unit, Otorhinolaryngology Department,
Hospital Clinic, IDIBAPS, Ciberes, Barcelona, Spain artery, which is smaller and more medial than the supraor-
e-mail: [email protected] bital artery, emerges through the orbital rim at approximately

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 183
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_16
184 A. Santamaría-Gadea et al.

form, transplanum, transclival, craniovertebral junction or

the septum) the required flap length would be different.
Some radiological studies have calculated the necessary PCF
size in each case [10, 12].

• Transcribriform approach: the PCF distal incision should

be carried at approximately 4 cm from the vertical projec-
tion of the external auditory canal on the skull (Fig. 16.2a).
• Transtuberculum approach: the PCF distal incision should
be placed at the level of the vertical projection of the
external auditory canal on the skull (Fig. 16.2b).
• Transclival approach: the PCF distal incision should be
almost 6 cm posterior to vertical projection of the external
auditory canal (Fig. 16.2c).
Fig. 16.1  Cadaveric dissection of PCF irrigation. SO supraorbital • Craniovertebral junction approach: the PCF distal inci-
artery, ST supratrochlear artery, blue line: orbital rim
sion should be carried out approximately 9 cm posteriorly
to the vertical projection of the external auditory canal
22.2 mm from the midline. In 92% of cases, the division into (Fig. 16.2d).
superficial and deep branches occurs at the level of the supra- • Total septal perforation reconstruction: the PCF distal
orbital rim or below. incision should be placed at the level of the vertical pro-
Although it is uncommon, the division of both arteries jection of the external auditory canal on the skull
into superficial and deep branches may occur above the (Fig. 16.2b).
orbital rim. Thus, it is recommended to avoid extending the
separation of the PCF from the galea–frontalis muscle layer Frontal sinus agenesis can be found in about 9% of the
into the 10  mm above the orbital rim, in order to prevent population [16]. These cases do not represent a limitation of
injury to the vascular supply. this technique; a new frontal sinus should be tailored to cre-
ate the passage of the PCF to the nasal cavity [12].

16.4 Preoperative Tips

16.5 Pearls and Potential Pitfalls
It has been well established that both in the repair of septal
perforations and in the repair of CSF leaks or skull base • The dissection between the PCF from the galea–frontalis
defects after advanced endoscopic approaches, pedicled muscle layer would preserve 10 mm above the orbital rim
endonasal flaps are the best reconstructive options. However, in order to prevent injury to the vascular supply [14].
in some situations, these flaps are not available or not large • The identification of the supraorbital notch also allows
enough to repair the skull base or septal defect. In these the location of the main pedicle of the PCF and get a bet-
cases, the use of the PCF introduced through the frontal sinus ter control during the dissection [12].
is recommended. The indications can be summarized as • The superficial temporal artery runs in the temporal area
follows. in front of the tragus, it is advisable to preserve it in case
future regional flaps are needed [14].
• Large septal perforation or near total septal perforation. • The incision should reach the roof of both helix in other
• When intranasal flaps are not available because vascular to improve the mobility of the skin portion of the scalp,
supply has been compromised or due to tumor invasion or facilitate the harvest of the PCF and its introduction into
prior use. the nasal cavity [11].
• Electrocautery could be used for scalp incisions, decreas-
On the contrary, the PCF would be contraindicated in ing operative times, and reducing blood loss, without
patients who underwent previous forehead surgery due to increasing complications such as alopecia, infection, and
damage to the flap blood supply or in the case of orbital rim dehiscence of incisions [17].
fractures. • Small osteotomy in the frontal sinus could induce irriga-
The PCF extends from the orbital rims to the occipital tion problems in the PCF and big osteotomy may provoke
area and presents a sufficient area to repair most of the ven- facial deformities. To avoid both complications, it is rec-
tral skull base defects or the entire nasal septum. Therefore, ommended to widen the inner face of the frontal bone
depending on the defect that we need to repair (transcribri- osteotomy [12].
16  Frontal Sinus Surgery (Draf III) as a Previous Step to More Complex Techniques Part 2 185

a b

c d

Fig. 16.2  Measurements performed in the CT scan study for skull base the reference point. (b) Transtuberculum approach: the incision should
reconstruction. Midline of the sagittal plane. Red line: skin. Yellow line: be placed at −0 cm from the reference point. (c) Clival approach: the
PCF. Blue line: the distance from the reference point to the limit of the incision should be placed at +6  cm from the reference point. (d)
PCF needed to reconstruct the different skull base approaches. (a) Craniovertebral junction approach: the incision should be placed at
Transcribriform approach: the incision should be placed at −4 cm from −9 cm from the reference point

• The entire mucosa of the posterior wall of the frontal • For skull base defects, the appropriate approach in
sinus is removed through an endoscopic or through the each case should be performed (Fig.  16.3). In septal
frontal osteotomy. This technique favors tissue healing perforation repair, the remnant nasal septum should be
and avoids mucocele formation [11]. prepared, dissecting the perforation edges to improve
• The frontal branch of the facial nerve runs within or just their binding to the flap (Fig.  16.4). At that time, a
deep to the superficial temporal fascia. To protect the Draf type III frontal sinusotomy is performed. The
motor innervation of the forehead, it would be advisable interfrontal sinus septum, the superior portion of the
to elevate the frontal branch of the facial nerve within the nasal septum, and the frontal sinus floor from orbit to
galea when it is dissected laterally [12]. orbit, are completely removed with an endoscopic
view [4].
• An external coronal incision is made at the vertex of the
16.6 Surgical Procedure Step by Step scalp from helix to helix. The incision is carried down to
loose areolar tissue. Then, the superficial portion of the
• First, the nasal cavity is decongested with Cottonoid pled- scalp (skin, subcutaneous tissue and aponeurotic layer) is
gets impregnated with a solution of adrenaline 0.001% carefully raised to prevent damage to the flap. At least
with lidocaine 2%. This improves hemostasis throughout 1 cm above the orbital rim needs to be preserved to pre-
the surgery. vent injury to the pedicles [14] (Fig. 16.5).
186 A. Santamaría-Gadea et al.

• Then, the posterior limit of the PCF is incised to the skull septum contain the periosteal surface [11]. To repair skull
bone according to the tissue extension required for com- base approach defect, a unilateral PCF should be recom-
plete closure of the defect (Preoperative tips section). mended in order to have the other side for salvage surgery
Laterally, the PCF is incised along the temporal lines. The [12] (Fig. 16.8).
PCF is raised to approximately 1 cm above the supraor- • To avoid long-term complications such as mucoceles, the
bital rims to again avoid damage to the pedicle of the PCF PCF is introduced into the nasal in the uppermost portion
[11, 12]. of the frontal sinus. Thus, we avoid the blockage of the
• In septal perforation repair, a bilateral PCF should be rec- frontal sinus ostium. For this purpose, the upper margin is
ommended. Bilateral PCF (Fig.  16.6) is folded back on located through sinus transillumination (Fig.  16.9).
itself to increase the thickness of the new nasal septum. Navigation can also be used to achieve this aim. Later on,
For this purpose, the PCF is sutured in its most distal area an anterior osteotomy of the upper portion of the frontal
with absorbable stitches (Fig.  16.7). It is important that sinus is drilled (Fig. 16.10). Under endoscopic view, the
when suturing the PCF, both external aspects of the new PCF is introduced through the osteotomy along the poste-
rior wall of the frontal sinus into the nasal cavity [11, 12]
(Fig. 16.11).
• Total septal perforation reconstruction: before the intro-
duction, the edges of the PCF should be marked with
stitches to facilitate insertion into the nasal cavity. After
the introduction of the PCF, the PCF must be rotated later-
ally 90° to be in a sagittal plane such as the nasal septum.
Then, the flap is sutured to the edges of the perforation.
The flap is sutured anteriorly and inferiorly to the remain-
ing mucosa of the septal perforation with absorbable
stitches. The posterior anchoring is made to the sphenoid
rostrum with two stitches that pass through two holes
made in the sphenoid rostrum, above the choanae
(Fig. 16.12a). The posteroinferior fixation is made with a
suture passing through the soft palate (Fig. 16.12b), thus
creating a new septum made of two layers of PCF
(Fig.  16.13). Silicone nasal splints are anchored to the
Fig. 16.3  Transcribriform approach for sinonasal tumor resection

a b

Fig. 16.4 (a) Total septal perforation. (b) Remnant nasal septum dissection at the level of the sphenoid rostrum (SR). * sphenoid ostium. † drilled
holes for posterior PCF attachments
16  Frontal Sinus Surgery (Draf III) as a Previous Step to More Complex Techniques Part 2 187

Fig. 16.5  Elevation of the most superficial layers of the scalp Fig. 16.7  Bilateral PCF folded onto itself and sutured with absorbable
stitches

Fig. 16.6  Bilateral PCF raised for total septal perforation reconstruc-
tion, just before being folded onto itself

Fig. 16.8  Unilateral PCF for skull base reconstruction in cadaver dis-
section. Frontal osteotomy in the uppermost portion of the frontal sinus
188 A. Santamaría-Gadea et al.

Fig. 16.11  PCF introduced into the nasal cavity through the frontal
sinus osteotomy

Fig. 16.9 Transillumination of the frontal sinus through nasal the PCF is introduced into the sinonasal cavity, the flap is
endoscopy placed between the bone and the dura, to repair the skull
base defect (Fig.  16.14). The periosteal surface of the
PCF is placed against the nasal cavity. The reconstruction
is bolstered in place with absorbable hemostatic material
and expandable packing sponges [12].
• A wound suction drain is placed at the scalp incision, and
a meticulous closure is performed. Afterward, a light
dressing is placed on the scalp to prevent subcutaneous
hematoma.

Advances in surgical techniques and instrumentation have

favored the reduction of the comorbidity of these approaches
by minimizing the incisions, making them almost impercep-
tible. Endoscopic elevation of the PCF with two incisions at
the level of the cranial vertex [8, 18] or a minimal vertical
incision in the frontal area [19] has been described.

16.7 Postoperative Tips

• The wound suction drain is removed 48 h after the

surgery.
• Antibiotic treatment is prescribed for seven days in all
patients.
• High flow nasal douching is prescribed for all patients.
• Patients are usually discharged between 4–7 days
postoperatively.
• Follow-up is once a week for the first month. The second
month is every 2 weeks. From the third month once a
Fig. 16.10  Frontal sinus osteotomy in its uppermost portion month until the sixth month. In some cases, it may be nec-
essary to increase the frequency of revisions. At each
anterior region of the remains of the nasal septum for 1 visit, endoscopic evaluation is performed to remove scabs.
month [10, 11]. • Septal perforation repair: soft nasal packing might be
• Skull base reconstruction: Multilayer technique with an used due to bleeding during the surgery, it will be removed
autologous graft (fascia lata) or synthetic dura inlay 48 hours after surgery. The silicone nasal splints will be
between the brain and the dura is performed. Then, once removed 4 weeks after surgery.
16  Frontal Sinus Surgery (Draf III) as a Previous Step to More Complex Techniques Part 2 189

a b

Fig. 16.12 (a) Posterior attachment of the flap to the sphenoid rostrum (SR). (b) Posteroinferior attachment of the PCF to soft palate. NS new
septum, LNW lateral nasal wall, C cavum. † suture passing through the soft palate

Fig. 16.13  Complete reconstruction of the nasal septum. (a) Endoscopic view of the right nasal fossa. (b) Endoscopic view of the left nasal fossa.
NS new septum, LNW lateral nasal wall, C cavum
190 A. Santamaría-Gadea et al.

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anterior ethmoidal cells. Ann Surg. 1899;29(2):175–217.
2. Chiu AG.  Frontal sinus surgery: its evolution, present standard
of care, and recommendations for current use. Ann Otol Rhinol
Laryngol Suppl. 2006;196:13–9.
3. Wormald PJ. Salvage frontal sinus surgery: the endoscopic modi-
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5. Messerklinger W.  On the drainage of the normal frontal sinus of
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DE. Anterior cranial base reconstruction: role of galeal and pericra-
nial flaps. Laryngoscope. 1990;100:607–14.
7. Patel MR, Shah RN, Snyderman CH, et al. Pericranial flap for endo-
scopic anterior skull base reconstruction: clinical outcomes and
radioanatomic analysis of preoperative planning. Neurosurgery.
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PA, Prevedello DM.  Minimally invasive endoscopic pericra-
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9. Majer J, Herman P, Verillaud B. “Mailbox Slot” pericranial
flap for endoscopic skull base reconstruction. Laryngoscope.
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in a cadaveric specimen. * frontal sinus. LP lamina papyracea. Red 10. Alobid I, Langdon C, Santamaría A. Technique to repair total septal
arrows anterior ethmoidal artery. White arrows posterior ethmoidal perforation with pericranial flap: “Money box approach”. JAMA
artery Fac Plast Surg. 2018;20(4):324.
11. Alobid I, Langdon C, López-Chacon M, Enseñat J, Carrau R,
• Skull base reconstruction: The nasal packing is removed Bernal-Sprekelsen M, Santamaría A. Total septal perforation repair
with a pericranial flap: radio-anatomical and clinical findings.
48 h after surgery. The remnants of hemostatic material Laryngoscope. 2017;128(6):1320–7.
are removed in the revisions. During each follow-up visit, 12. Santamaría A, Langdon C, López-Chacon M, Cordero A, Enseñat
the absence of CSF leakage is checked. J, Carrau R, Bernal Sprekelsen M, Alobid. Radio-anatomical analy-
sis of the pericranial flap “Money Box Approach” for ventral skull
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13. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ.  The surgical
16.8 Conclusion anatomy of the scalp. Plast Reconstr Surg. 1991;87:603–14.
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Ashwini LS, Mohandas Rao KG, Saran S, Somayaji
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 External Approaches to the Frontal
Sinus. Osteoplastic Flaps 17
With or Without Frontal Sinus
Obliteration

Daniel Pedregal, David Lobo, Jose Luis Llorente,

and Roberto Megía

17.1 Historical Review frontoethmoidectomy through the medial orbital wall. Lothrop
in 1914 introduced a combined external and intranasal
External techniques for frontal sinus surgery have been approach to remove the ethmoidal cells, bilateral frontal sinus
replaced by endoscopic approaches in most of the frontal sinus floors, the superior nasal septum, and intersinus septum [5].
pathology, but there are still several indications for open sur- This procedure was dangerous and technically difficult, and
gery. The earliest frontal obliteration with a trephine is attrib- the resection of the medial orbital wall and frontal floor caused
uted to Runge in 1750 [1], but the first report of open frontal the collapse of the orbital soft tissue into the ethmoid area,
sinus approaches to drain frontal sinus pyoceles was published narrowing the frontal drainage pathway [6]. For these reasons,
by Wells in 1870 [2]. In 1884, Ogston proposed frontal sinus the Lothrop procedure was put aside until its modification to
trephination via a forehead incision and communication with an endonasal endoscopic operation by Draf. Other modifica-
ethmoid sinus for treatment of sinus infection [3]. Soon after, tions of external frontoethmoidectomy with better cosmetic
in 1896, a very similar procedure, the Ogston–Luc technique, results were developed by Lynch and Howarth in 1921. The
was described [4]. As an alternative to the Ogston–Luc proce- Lynch–Howarth procedure was based on a medial periorbital
dure, frontal sinus obliteration was introduced. Kuhnt incision, the removal of ethmoidal cells, and a portion of the
described in 1895 the removal of the anterior wall of frontal frontal floor with stent placement to ensure drainage. Some
sinus and Riedel in 1898 the obliteration of the frontal sinus, modifications of the Lynch–Howarth procedure included the
stripping all the mucosa, and redraping the skin of the fore- addition of a septal flap (Sewall–Boyden) and the use of
head [4]. The new technique provided better disease control, Silastic™ stents (Neel–Lake), but their poor long-term results
but significant cosmetic deformity, so Killian modified the led to a decrease in the use of this technique [7, 8]. Regarding
procedure by preserving a small bridge of mucosa and bone the osteoplastic approach to the frontal sinus, it was first
across the supraorbital rim. However, the Killian alternative described by Schonborn in 1894 and Brieger in 1895 [9] and
had high morbidity and failure rates, so it was abandoned. The later modified by Hoffman in 1904 with the obliteration proce-
disfiguration caused by obliterative procedures led to explor- dure. However, the osteoplastic flap (OPF) did not gain popu-
ing the possibility of enlarging the nasofrontal outflow tract. In larity until the introduction of the eyebrow incision in 1934 by
1908, Knapp proposed the entry to the frontal sinus with a Bergara. The modern concept of the OPF comes from the
studies of Macbeth (1954), who introduced the bicoronal inci-
Supplementary Information The online version contains supplementary sion for a large flap [10]. After the series published by Goodale
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_17]. and Montgomery in 1958, where OPF with fat obliteration
showed high success rates, this procedure became the standard
D. Pedregal · J. L. Llorente of care until the rise of the endoscopic era. The flap and newer
Department of Otolaryngology-Head and Neck Surgery, Hospital obliteration techniques avoided significant facial deformity.
Universitario Central de Asturias, Oviedo, Spain
D. Lobo
Department of Otolaryngology, Marqués de Valdecilla University 17.2 Indications
Hospital, Valdecilla Biomedical Research Institute, Santander,
Spain
e-mail: [email protected] Endoscopic sinus surgery has replaced open approaches in
many diseases of the frontal sinus since its introduction in the
R. Megía (*)
Department of Otolaryngology-Head and Neck Surgery, University 1980s. The limits of the endoscopic surgery are constantly
Hospital Marqués de Valdecilla, Santander, Spain evolving with advances in technique and instrumentation.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 191
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_17
192 D. Pedregal et al.

Table 17.1  Indications for open frontal sinus surgery sinus, involving the posterior table above the isthmus of the
Chronic frontal rhinosinusitis with prior failed endoscopic frontal recess.
procedures Frontal sinus benign tumors (inverted papilloma, osteo-
Acute frontal sinusitis with impending complications mas) and malignancies can be managed with an external
Osteomyelitis of the frontal bone
approach in cases of multifocality or far lateral, supraorbital,
Lateral frontal sinus mucoceles
or anterior frontal table attachments. Generally, open
Osteogenesis or injury of the frontal recess
Frontal bone fractures with comminuted bone
approaches should be considered when endoscopic visual-
Endoscopically inaccessible benign and malign frontal sinus tumors ization or reach of instrumentation is suboptimal.
Cerebrospinal fluid (CSF) leaks and/or encephaloceles Considering that frontal sinus trephination is a less
Pneumatocele causing cosmetic deformity aggressive alternative to OPF, in some situations where an
endoscopic approach is insufficient, the Endoscopic Frontal
Trephination (EFT) combined with another endoscopic
However, in the endoscopic era, certain situations persist in approach (“above and below” technique) may be suitable
which open frontal sinus surgery has its indication [11] and an alternative to more invasive procedures. Another
(Table  17.1). In addition, combined open and endoscopic option is the combination of the OPF with the endoscopic
frontal sinus procedures are also becoming more prevalent. approach, which is also considered an “above and below”
For inflammatory frontal sinus disease, external technique that is useful to manage neo-osteogenesis of the
approaches are reserved for those cases where prior endo- frontal recess [12] (Table 17.2).
scopic procedures failed or with pathological conditions that
could predispose to that failure, such as distortion of critical Table 17.2  Modern external frontal sinus procedures and indications
landmarks, neo-osteogenesis of the frontal recess, and lateral Frontal sinus trephination •  Far-lateral frontal sinus lesions
location of diseased mucosa [12, 13]. Factors associated with and “above–below” • Large tumors or inflammatory
neo-osteogenesis include previous trauma, endoscopic sur- approach lesions (mucocele, osteoma,
gery, and frontal bone osteomyelitis. Frontal sinus is the inverted papilloma, fibrous
dysplasia)
most common location of mucoceles, due to obstruction of • Trauma with distorted frontal recess
the frontal ostium. Although mucoceles can be managed or posterior frontal wall damage
with endoscopic drainage, some cases require a combined • Serious disruption of the frontal
external and endoscopic approach to remove the mucocele recess
• Revision surgery with extensive
completely and, keeping in mind that frontal sinus surgery scarring or neo-osteogenesis
increases the risk of recurrent mucocele, frontal sinus oblit- •  Pott’s puffy tumor
eration must be considered. Frontal bone osteomyelitis is a •  Type 3 or 4 frontal cells
complication of acute or chronic rhinosinusitis that can Lynch–Howarth •  Frontal sinus fractures
procedure (Neel–Lake • Extensive bony destruction of the
involve the frontal periosteum or spread intracranially and
modification) frontal sinus
may need external surgery if medical treatment fails. Another • Prior failed external frontal sinus
important anatomical consideration is the presence of type 3 surgery
and 4 frontal cells (according to Kuhn Classification) located Osteoplastic flap (with or • Lesions of the frontal sinus too
in the superolateral aspect of the frontal sinus, because they without obliteration) lateral for endoscopic access
• Impairment of the frontal sinus
can make its removal technically very challenging through drainage pathway not amenable to
an endoscopic approach, requiring a combined approach. endoscopic surgery
Facial trauma resulting in the fracture of the anterior or • Frontal bone fractures requiring
posterior table of the frontal sinus, or the frontal recess, can external approach for reduction,
fixation, and/or dural repair
create scarring and thickened bone that prevent endoscopic • Prior failed endoscopic surgeries for
access, and complex or comminuted fractures will require an chronic frontal rhinosinusitis
open approach for reduction and fixation. Open surgery, Riedel’s procedure •  Failure of frontal sinus obliteration
mainly OPF, is suggested as the primary management of • Tumors or osteomyelitis with
involvement of the anterior table of
frontal sinus fractures [14].
the frontal sinus
Traumatic, iatrogenic, or spontaneous cerebrospinal fluid Frontal sinus •  Anterior skull base tumors
(CSF) leaks and/or encephaloceles can require external cranialization • Posterior table fracture with CSF
(frontal trephine or OPF) or combined approaches when the leak, displacement, or comminution
defect is located superiorly or laterally within the frontal (>25% of the sinus)
17  External Approaches to the Frontal Sinus. Osteoplastic Flaps With or Without Frontal Sinus Obliteration 193

17.3 Preoperative Tips

17.3.1 Anatomy

The scalp is composed of soft tissue layers that cover the

cranium.
The mnemonic SCALP indicates the five layers of the
scalp: skin, connective tissue, galea aponeurotica, loose are-
olar connective tissue, and pericranium.
The first layer is the skin, which is thick and contains hair
follicles and sebaceous glands. The hair follicles can extend
into the dense connective tissue layer, where the nerves, lym-
phatics, and the vascular supply of the scalp reside.
The galea consists of the aponeurosis between the fronta-
lis and occipitalis muscles and is contiguous with the tempo-
roparietal fascia, as well as the superficial aponeurotic
system (SMAS) of the face. These first three layers are firmly
Fig. 17.1  Image showing how to obtain the template of the X-ray
attached and they move as a single unit.
image
The loose connective tissue is important for the mobility
of the scalp. It also serves as a flexible plane that separates
the top three layers from the pericranium. –– Oscillating saw.
The pericranium is the deepest layer of the scalp which –– Osteotomes.
corresponds to the periosteum that attaches to the bones of –– Ear surgery motor with diamond and cutting burs.
the calvaria, providing them with vascular supply [15]. –– Endoscopy room setup.
The temporoparietal fascia is the most superficial fascial –– Intraoperative navigation system.
layer and it is an important anatomic landmark. The superfi- –– Separate instrumentation for abdominal fat collection.
cial temporal vessels run along the outer aspect of it, and the
frontal branch of the facial nerve runs on its deep surface.
The temporalis fascia invests the temporalis muscle and is 17.4 Pearls and Potential Pitfalls
fused with the pericranium at the superior temporal line [16].
Accurate preoperative evaluation and planning are neces-
sary to perform external frontal sinus surgery. Besides nasal
17.3.2 Imaging Pre-op endoscopic examination, all patients should undergo com-
puterized tomography (CT) prior to surgery to review the
A CT scan, and also an MRI scan in the case of tumors, are anatomy and the location of the disease. CT scan must be
necessary to determine whether an endoscopic approach is carefully studied in three planes (coronal, axial, and sagit-
possible or if an external approach by means of osteoplasty tal) paying attention to the depth of frontal pneumatization
is required. (sagittal view) to assess feasibility and safety of external
If we are planning the osteoplasty, a posteroanterior X-ray approaches that will involve sawing or drilling the anterior
with the plate in the frontal area must be done, to obtain an frontal table, as well as the location of the anterior eth-
image of the frontal sinuses that is closer to their real size. A moidal artery. Other issues to take into consideration
template of the frontal sinuses will be sterilized and available include the presence of sequelae from previous surgeries,
during surgery [11, 17]. See Fig. 17.1. Alternatively, if navi- soft tissue infection, mucocele, mucopyocele, or cranial
gation is available, it can assist in determining the location of nerve abnormalities. Magnetic resonance imaging (MRI)
the osteotomies. may be necessary to assess orbital, dural, and perineural
Otherwise, transillumination of the sinuses can be carried invasion. MRI is also useful to distinguish mucoceles from
out, but may be unreliable if the sinuses are very occupied. tumors and fat in patients with previous obliteration proce-
dures. A multidisciplinary approach with the participation
of neurosurgeons must be considered when malignancies or
17.3.3 Instrumentation other lesions show a notable invasion in the anterior cranial
fossa.
–– Head and neck surgery instrumentation. If the frontal sinus is obliterated, postoperative mucocele
–– Hemostatic scalp material (Dandy curved forceps and formation must be prevented with the complete removal of
Raney clips). all the sinus mucosa during the obliteration procedure. The
194 D. Pedregal et al.

choice of the obliteration material is another important point. The cosmetic appearance is a noteworthy consideration
Autologous abdominal fat is the most used element nowa- regarding the outcome of the open surgery in this location.
days. Frontal sinus obliteration with hydroxyapatite and Cases with prior surgeries or complex fractures of the frontal
other foreign materials may be associated with increased sinus may require the collaboration with a plastic surgeon to
rates of infection, flap necrosis, and graft extrusion [18] achieve better cosmetic results. In selected patients, delayed
(Figs. 17.2 and 17.3). reconstruction surgery can be performed.
Image guidance with triplanar views is extremely useful
in planning the external frontal approach and appears to
improve intraoperative safety and reduce the rate of intraop- 17.5 Surgical Procedure Step by Step
erative complications [19, 20]. Three-dimensional intraop-
erative navigation allows mapping out the bilateral frontal The patient is positioned supine with the head elevated to
sinuses on the patient’s frontal bone. An alternative is the 10°–15°.
delineation with an onlay template generated preoperatively The incision can be coronal, through a frontal crease, or
using 3D models extracted from CT scans [21]. If these bilateral supraciliary (gullwing). Coronal incision is prefer-
options are not available, the classic employment of an X-ray able as it is more aesthetic and has minimal risk of supraor-
film of a Caldwell view as a template or transillumination bital nerve damage. If the patient is bald or balding, the
can be useful, but image guidance has been demonstrated to incision can be performed in a frontal crease with minimal
be superior to both modalities [8]. aesthetic sequelae. Bilateral supraciliary incision is not rec-
ommended as it has poorer cosmetic results and a higher risk
of supraorbital nerve damage [22, 23] (Fig. 17.4).
If we choose a coronal incision, we can shave the incision
line, or we can collect the long hair with rubber bands and
separate the short hair with hair spray [24, 25] (Fig. 17.5).
We disinfect the skin, infiltrate with Klein’s solution, and
cover with a surgical drape.
The corneas are protected with a temporary tarsorrhaphy
or ophthalmic ointment and adhesive skin suture.
The standard coronal incision, when exposure is limited
to the supraorbital region, runs from the level of the auricular
helix to the contralateral helix, approximately 2–3 cm poste-
rior to the hairline. The traditional incision is bow-like, but
Fig. 17.2  Complex reconstruction of a frontal sinus osteoma with
geometric patterns (sawtooth, stepwise, or wavelike designs)
hydroxyapatite obliteration and a mesh are recommended because the scars may be less noticeable,
especially when hair is wet (Fig. 17.4). Furthermore, these
types of incisions allow for an accurate reapproximation dur-
ing closure [24].
The incision is made supraperiosteally and tissue is dis-
sected down to the level of the supraorbital rim. The tempo-

Fig. 17.3  Reconstruction of the frontal sinus with bone and oblitera- Fig. 17.4  Photograph showing potential incision sites (red lines) for
tion with hydroxyapatite accessing the frontal sinus
17  External Approaches to the Frontal Sinus. Osteoplastic Flaps With or Without Frontal Sinus Obliteration 195

Fig. 17.7  Beveled osteotomy

Fig. 17.5  Photograph at the end of the procedure showing the hair col-
lection with rubber bands and hair spray. Closure of coronal incision

Fig. 17.8  The osteoperiosteal flap is elevated, exposing the frontal

sinus

The intersinus septum is then cut with the saw or with a

6–9 mm osteotome. This is necessary to allow the anterior
frontal sinus table to separate from the posterior table.
Fig. 17.6  Photograph showing the application of a Rx template to out-
line the sinus The 7–12 mm osteotome is then used to pry the anterior
frontal sinus table forward; causing a fracture above both
orbital roofs, and the osteoperiosteal flap is elevated, expos-
ral fascia should be respected in order to preserve the frontal ing the frontal sinus [25] (Fig. 17.8).
branch of the facial nerve [17, 22]. Some authors perform the dissection subperiosteal and
The prefabricated template helps to define the extent of after that they removed entirely the anterior table and stored
the frontal sinuses. See Fig.  17.6. If we have a navigation it in sterile saline for replating and screwed at conclusion of
system, we use it to confirm the anatomic references [17]; the procedure [17, 22, 26].
otherwise, we can use transillumination of the sinuses. The Once the sinus lesion has been addressed (e.g., excised,
contour of the frontal sinus is marked with methylene blue. drained), we must determine if the sinus functionality can be
An incision is then made in the periosteum 1 cm above the restored or if the sinus should be obliterated.
osteotomy line and the periosteum is separated from the If the frontal recess is undisturbed and removal of the
bone up to 1 cm below the osteotomy line. lesion does not disrupt more than one half of the frontal sinus
With a 9–10 mm. flat oscillating saw, we perform a bev- mucosa, the remainder may be left intact, especially if it is
eled osteotomy along the superior border of the sinuses. The combined with an endoscopic approach, like Draf II or Draf
saw should be introduced at an angle of 30°–45°, which will III [22].
ensure that we enter the sinuses and not the cranial cavity Otherwise, the sinus should be obliterated, for which
and also allows it to be repositioned by suturing the perios- complete removal of the sinus mucosa is essential, and the
teum without the need for osteotomy plates [11] (Fig. 17.7). mucosa of the frontal recess is inverted (Fig. 17.9).
196 D. Pedregal et al.

Fig. 17.9  Intraoperative frontal sinus with a meticulous resection of all

mucosa by drilling with microscopy

A high-speed diamond bur is used to polish the bone. It is

critical to address all areas of the frontal sinus. The anterior
table is also treated in the same manner. Drilling of the bone
walls with a large diamond bur has the dual purpose of
removing any residual mucosa and promoting neo-­ Fig. 17.10  Intraoperative hydroxyapatite preparation
osteogenesis [27].
However, some authors suggest that the viability of the fat
graft is dependent on in-growth of blood vessels from the anterior wall of the sinus is damaged by osteomyelitis or
posterior wall, and a diamond burr seals these vessels and fractured with severe comminution, it is possible to fill the
may prevent or delay in-growth of blood vessels into the fat sinus with bone cement and reconstruct the anterior wall
graft. They propose using a cutting burr instead [25]. simultaneously [23] (Figs. 17.10 and 17.11).
Once this step is completed, the mucosa of the frontal The harvest of fat is performed using sterile technique,
recess is inverted, the frontal recess is plugged with fascia or with a separate surgical field, using new surgical gloves and
temporalis muscle and the sinus is obliterated. instrumentation that has not come into contact with the con-
Biological or synthetic materials can be employed to fill taminated area.
the sinus. Although there is no consensus on which is the The incisions that can be made include transverse incision
best material for obliterating the frontal sinus, it seems that in the lower left quadrant, a periumbilical incision or supra-
the method of obliteration is not critical to the outcome of the pubic incision (Pfannenstiel) [25].
procedure. Meticulous removal of all the frontal sinus After obliteration, the osteoplastic flap is repositioned
mucosa and permanent occlusion of the nasofrontal ducts are and the periosteum sutured so that it will remain in position
crucial [28]. without the need for osteotomy plates (Figs.  17.12 and
The two most commonly used materials are autologous 17.13).
fat and hydroxyapatite. Suction drain is placed and closure is performed in two
Fat has many advantages as a sinus-filling material, since planes: the galea with resorbable suture and staples in the
it is an autologous material, rejection is practically nonexis- skin (Fig. 17.5).
tent, has a good resistance to infection, and is easy to mobi- The drain is removed in 2  days, and the staples are
lize and manipulate [26, 27]. removed approximately 10 days after surgery [25].
The use of bone cement (hydroxyapatite) for obliteration The administration of prophylactic or postoperative anti-
is not usually recommended due to the increased risk of biotics depends on the pathology and also on whether the
infection and the need for revision [22]. However, when the obliteration is performed or not.
17  External Approaches to the Frontal Sinus. Osteoplastic Flaps With or Without Frontal Sinus Obliteration 197

Fig. 17.11  Postop CT showing a proper frontal obliteration Fig. 17.13  Closure of an osteoplastic flap with a microplate and cover
with a pericranial flap

Fig. 17.12  Osteoplastic flap repositioning and fixation with periosteal

suture without the need for osteotomy plates

17.6 Postoperative Tips

Employing a meticulous surgical technique in well-selected Fig. 17.14  Postop scar of the coronal incision of the patient from
patients, external frontal sinus approaches are safe, have Fig. 17.5
excellent results, and are associated with low revision rates
[18, 29] (Figs. 17.3, 17.5 and 17.14). Surgical strategies to be done (Figs. 17.9 and 17.10). In obliterative procedures, fat
avoid complications depend on the type of procedure. For donor site morbidity (scar, infection) should be observed.
nonobliterative surgeries, mucosal preservation and careful Cosmetic wound healing is also an important point in
dissection of the frontal recess are critical [30]. Scarring of external techniques. The position of the incisions and suture
frontal recess or neo-osteogenesis can cause refractory dis- techniques can lead to alopecia and broad scars (Fig. 17.15),
ease, recurrent infection, or secondary mucoceles. In oblit- so these steps of the surgery must be planned and performed
erative surgery, meticulous resection of all mucosal lining carefully. Other potential complications of external sinus
and complete closure of the frontal ostium and recess must approaches are frontal depression (due to poor positioning or
198 D. Pedregal et al.

xylometazoline). If the Lynch–Howarth procedure is per-

formed (with Neel–Lake modification), a rolled Silastic™
sheet should be used to stent the nasofrontal duct.
Postoperative pain may be a problematic issue in external
procedures. It is caused by a lesion of the supraorbital nerve
or by the heat generated during drilling. If bone healing is
interfered with due to different causes (e.g., infection, extru-
sion, trauma), chronic postoperative pain may appear. To dis-
tinguish these situations from recurrent frontal sinusitis,
radiologic imaging is necessary since endoscopic examina-
tion is of limited value in those cases. CT and MRI with fat
suppression are very useful because they provide details for
distinguishing mucoceles, disease recurrence, or intracranial
complications (Fig. 17.11). Other neurologic complications
can result from the lesion of the supratrochlear nerve or the
frontal branch of the facial nerve.
In OPF, Riedel’s procedure, and frontal sinus cranial-
Fig. 17.15  Anterior unilateral approach with potential evident scar ization, a closed-suction drain is placed for at least 3 days
to prevent hematoma. After Riedel’s procedure, delayed
reconstruction could be considered to reduce facial
disfigurement.
In combined approaches, postoperative debridement
(blood clots, mucous plugs, debris, granulation tissue, undis-
solved packing) may be necessary and is associated with
improved healing. Nasal saline irrigation should be started in
the early postoperative period, which has an additive effect
with debridement. The use of topical steroids (irrigations,
sprays, or drops) after surgery is supported by evidence, but
the use of systemic steroids is controversial.

References
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Donald PJ, Gluckman JL, Rice DH, editors. The sinuses. New York:
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resorption of the osteoplastic flap 2. Wells R. Abscess of the frontal sinus. Lancet. 1870;1:694–5.
3. Ogston A. Trephining the frontal sinus for catarrhal diseases. Med
Chron. 1884;3:235–8.
4. McLaughlin RB Jr. History of surgical approaches to the frontal
poorly healed bone flap) (Fig. 17.16), exposure of implants sinus. Otolaryngol Clin North Am. 2001;34(1):49–58.
or hardware, and chronic frontal osteomyelitis with or with- 5. Lothrop HA. XIV. Frontal sinus suppuration: the establishment of
out fistula. permanent nasal drainage; the closure of external fistulae; epider-
Prophylactic antibiotics are indicated, but it is unclear mization of sinus. Ann Surg. 1914;59(6):937–57.
6. Gross WE, Gross CW, Becker D, Moore D, Phillips D. Modified
whether therapy should be continued. In cases of posterior transnasal endoscopic Lothrop procedure as an alternative
table erosion, cerebrospinal fluid leak, or dural tears, intrave- to frontal sinus obliteration. Otolaryngol Head Neck Surg.
nous antibiotics should be administered prophylactically 1995;113(4):427–34.
when performing surgical repair. If mucopyocele or frontal 7. Murr AH, Dedo HH.  Frontoethmoidectomy with Sewall–Boyden
reconstruction: indications, technique, and philosophy. Otolaryngol
sinusitis is present, antibiotic therapy should be guided by Clin North Am. 2001;34(1):153–65.
culture of specimens obtained during surgery. 8. Neel HB 3rd, McDonald TJ, Facer GW. Modified lynch procedure
In cases of acute infection, after frontal sinus trephina- for chronic frontal sinus diseases: rationale, technique, and long-­
tion, two cannulas are placed with a catheter for irrigation, term results. Laryngoscope. 1987;97(11):1274–9.
9. Friedman WH.  External approaches to the frontal sinuses. In:
and a truncated catheter for egress of irrigation. The irriga- Kennedy DW, Bolger WE, Zinreich SJ, editors. Diseases of the
tion is performed 3–4 times a day with saline or a mixture of sinuses: diagnosis and management. 1st ed. Raleigh: PMPH–USA;
saline with nasal decongestant spray (oxymetazoline or 2001. p. 391–403.
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10. Macbeth R. The osteoplastic operation for chronic infection of the 21. Berens AM, Davis GE, Moe KS.  Transorbital endoscopic iden-
frontal sinus. J Laryngol Otol. 1954;68(7):465–77. tification of supernumerary ethmoid arteries. Allergy Rhinol
11. López Llames A, Llorente Pendás JL, Suárez Fente V, Burón
(Providence). 2016;7(3):144–6.
Martínez G, Suárez Nieto C. Osteoplastia frontal: nuestra experien- 22. Ference H, Welch K. Osteoplastic flaps with and without oblitera-
cia [Osteoplastic flap: our experience]. Acta Otorrinolaringol Esp. tion. In: Chiu AG, Palmer JN, Adappa ND eds. Atlas of endoscopic
2003;54(6):429–34. sinus and skull base surgery. 2nd Philadelphia: Elsevier 2019:
12. Hahn S, Palmer JN, Purkey MT, Kennedy DW, Chiu AG. Indications 309–316
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the endoscopic era. Curr Opin Otolaryngol Head Neck Surg. 24. Cornelius C-P, Gellrich N, Hillerup S, et  al. Coronal approach.
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14. Lee YH, Lee JY, Lawson W. Indications and outcomes of the osteo- face/approach/coronal-­approach. Accessed 1 Jul 2021.
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Surg. 2020;31(8):2243–9. fat obliteration. Oper Tech Otolayngol Head Neck Surg.
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Island, FL: StatPearls; 2021. https://www.ncbi.nlm.nih.gov/books/ 26. Fokkens W, Harvey R.  Management of the frontal sinuses. In:
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2021. 27. de Régloix SB, Maurin O, et  al. Tratados EMC: cirugía

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1994;111(6):727–32. 29. Ochsner MC, DelGaudio JM.  The place of the osteoplastic flap
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JP.  Computed tomography image guidance for more accurate 2015;125(4):801–6.
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757126.
 Indication of Frontal Sinus Trephination
Procedure 18
Roberto Megía, David Lobo, and Jaime Viera

18.1 Introduction Frontal trephination allows surgery to be performed

through a small and well-camouflaged external incision
The frontal sinus trephination should not be regarded as a without disruption of the frontal sinus outflow tract.
procedure of the past, although its use is not common, it is Frontal trephination as an adjunct to standard endoscopic
useful in the armamentarium of the modern sinus and skull frontal sinus surgery is a useful mode of treatment for fron-
base surgeon. This approach provides access for instrumen- tal sinus pathology in patients with unfavorable endoscopic
tation for hard-to-reach frontal sinus disease (e.g., lateral and anatomy. It allows for greater manipulation of the sinus con-
superior) either purely through a trephination approach or as tents and spares the patient more invasive and potentially
a supplementation to the transnasal endoscopic approach. It riskier procedures.
can be a valuable alternative to more aggressive procedures
such as an osteoplastic flap.
This approach was first described by Runge in 1750, and 18.2 Indications
Ogston and Hutchinson further described the procedure in
1884 and 1939 as a puncture technique into the frontal sinus [1, The authors perform a frontal sinus trephine as an adjunct to
2]. Historically, trephination has been used to emergently treat endonasal techniques only if the target region is not acces-
acute frontal sinusitis or complications related to acute frontal sible via standard endoscopic approaches.
sinusitis. In 1991, Hoffman and May described an “above and
below” approach to the frontal sinus using the trephine port- Non-inflammatory disease
hole [3]. However, a mini or megatrephination can also provide • Osteomas: osteoma removal using frontal trephination as
an additional porthole for endoscopic visualization and instru- an adjunct to endoscopic sinus surgery via an “above and
mentation to treat several pathologies in the frontal sinus. below” approach [4].
Although transnasal endoscopic approaches can be –– Repair of frontal sinus fractures: Depressed fractures of
attempted for pathology in the lateral frontal sinus, the anat- the anterior table can be elevated through a trephine with
omy is often not conducive to such approach in addition to a curved clamp or probe, with the placement of a bal-
the longer operative time and surgical skill required. The loon catheter inside the sinus if the fracture segments are
endoscopic endonasal approach is typically limited to the unstable [3–5]
midpoint of the orbit. Trephination allows for more lateral –– Other non-inflammatory pathologies: Fibrous dysplasia.
visualization and instrumentation [4]. Posterior table fracture repair. Meningioma. Pneumocephalus,
inverted papilloma [6], other benign tumors, CSF leaks repair
Supplementary Information The online version contains supplementary [2, 7].
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_18].
Inflammatory disease
R. Megía (*) · J. Viera • Narrow or ossified frontal recess. Frontal recess stenosis.
Department of Otolaryngology-Head and Neck Surgery, University Obstructing frontal cells (lateral and superior frontoeth-
Hospital Marqués de Valdecilla, Santander, Spain moidal cells and intersinus septum cell) [8]. Major chal-
D. Lobo lenge in finding frontal recess [3].
Department of Otolaryngology, Marqués de Valdecilla University –– Dissection aid during Draf III.
Hospital, Valdecilla Biomedical Research Institute, Santander,
–– Acute frontal sinusitis that does not respond to adequate
Spain
e-mail: [email protected] medical treatment. This procedure can often be performed

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 201
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_18
202 R. Megía et al.

under local anesthesia in the office; it allows immediate

drainage and culture of infected material, and provides a
portal for irrigation of the frontal sinus [9].
–– Pediatric frontal sinusitis.

Consider frontal sinus trephination when endoscopic

techniques cannot adequately address disease processes.
Consider the use of a combined endoscopic-trephina-
tion approach versus the need for a conventional exter-
nal approach such as the osteoplastic flap technique, with
­indications including unfavorable anatomy, lateral disease,
and scarring.

18.3 Schematic Description

(Anatomy—Expected Result)
Fig. 18.1  Figure showing the supraorbital and supratrochlear nerves,
The frontal sinus is a pyramidal structure that resides in medial and lateral limits of the incision
the anterior cranial vault and is enveloped by two layers of
cortical bone: a thick anterior table and a thinner posterior
table.
The anterior wall ranges from 4 to 12 mm in thickness. 18.4 Preoperative Tips (Individual Risk
From superficial to deep, it is covered by layers of skin, sub- Factors, Radiology, Instrumentation)
cutaneous fat, the frontalis muscle, and the pericranium.
The intersinus septum is a triangular bony structure that Frontal sinus trephination is ideal in cases in which a purely
separates the frontal sinus into two independently draining endoscopic approach is not feasible and an open osteoplastic
cavities. It can vary in its position so that the frontal sinus flap procedure is too aggressive.
cavities may be asymmetric. If there is any doubt as to whether the frontal sinus can
The size and depth of the frontal sinus are very vari- be accessed endoscopically, consent for a trephine procedure
able. The frontal sinus depth measured at 5  mm of the should be obtained before surgery.
midline is significantly larger than that at 10- and 15-mm. The overall medical condition of the patient should be
Men present a significantly larger frontal sinus compared taken into consideration, since trephination and frontal sinus
to women [10]. drainage can often be done faster than an endoscopic proce-
The supraorbital and supratrochlear nerves innervate the dure requiring excessive drilling of the frontal recess [11].
soft tissue anterior to the frontal sinus and nearby areas. Obtain a computed tomography (CT) scan of the parana-
The supraorbital nerve is located at the superior medial sal sinuses before the procedure. During preoperative analy-
orbital rim about a finger-breadth medial to the mid-­pupillary sis of the CT, perform a systematic review of the images with
line. The supratrochlear nerve lies about 1.5 cm farther medi- attention to the following anatomic features:
ally near the medial margin of the eyebrow.
The supraorbital nerve passes through the supraorbital –– Height and depth (anterior to posterior distance) of the
foramen (located just above the upper rim of the orbit at the frontal sinus. On average, male patients have deeper fron-
junction of its medial and lateral two-thirds), courses deep to tal sinuses.
the corrugator muscle, then penetrates superiorly through the –– Dehiscence of the superior orbital roof.
frontalis muscle. –– Dehiscence of the anterior or posterior table of the frontal
The supratrochlear nerve passes superior to the troch- sinus.
lea of the superior oblique muscle and exits medially to the –– Presence of frontal sinus cells.
supraorbital foramen and passes around the superior orbital –– Thickness of the nasofrontal bone.
rim, deep to the frontalis muscle [11] (Fig. 18.1). –– Thickness of the nasofrontal floor (average is 4 mm) [11].
18  Indication of Frontal Sinus Trephination Procedure 203

Image guidance is used to plan the approach and avoid an

intracranial breach.
The combined use of a frontal sinus trephine with endo-
scopic frontal sinus surgery often spares the patient the need
for more invasive procedures.

Necessary instrumentation
–– 0°, 30°, and 70° endoscopes.
–– No. 15 scalpel blade.
–– Self-retaining retractor.
–– Two-pronged skin hook.
–– Bipolar cautery or Colorado tip.
–– Periosteal elevator or Freer elevator.
–– 3–4 mm round bur.
–– Fine suction device.
–– Kerrison rongeur.

18.5 Pearls and Potential Pitfalls

The incision, although described at the medial infrabrow, can

be tailored to the location of the lesion. When a brow inci-
sion is created, the scalpel should be beveled to preserve the
brow trichia and to avoid eyebrow alopecia [12].
Considering the safety of the procedure, the ideal location Fig. 18.2  Four different incisions can be made: (1) Suprabrow inci-
sion. (2) Intrabrow incision. (3) Infrabrow incision. (4) Upper eyelid
for trephination is 10 mm from the midline. Performing the crease incision
trephination at 10 mm rather than at 5 or 15 mm from the
midline has the advantage of avoiding cross trephination in
asymmetric sinuses and the risk of sinus hypotrophy respec- system is being used that requires a guidance headset or
tively [13]. headband, place it sufficiently above the eyebrow to allow
However, the depth of the frontal sinus at several points adequate space for surgical access.
medial to lateral should be determined before surgery. The The medial brow is injected with 1% lidocaine with epi-
average anteroposterior diameter (frontal sinus depth) is nephrine 1:100,000. In general, four different external inci-
smaller in females. Image guidance can be used to identify sion lines have been used: within the eyebrow, below the
the anterior frontal table of the frontal sinus and locate the eyebrow, above the eyebrow, and the upper eyelid crease.
safest area for the trephine. Each approach has certain advantages and disadvantages in
Bone drilling should be performed carefully to avoid sud- terms of the resultant scar, adequacy of drainage, endoscopic
den entry into the posterior sinus table. The opening should assessment, the safety of trephination, the potential for nerve
be enlarged only to the size needed. or vessel injury, and the risk of complicated bone infection
An acutely infected sinus should not be entered through [7–11] (Fig. 18.2).
the anterior table to avoid the spread of infection and second- Our preference is to perform it approximately 1–1.5  cm
ary osteomyelitis [13]. from the midline in the inferomedial margin or, more rarely,
in the middle of the eyebrow (Fig.  18.3). If the incision is
made inside the eyebrow a 0.5–1-cm brow incision is created,
18.6 Surgical Procedure Step by Step with the scalpel beveled to preserve the brow trichia, to avoid
eyebrow alopecia and to achieve a better aesthetic result. The
Frontal trephination is best performed with the patient under cutaneous incision can be widened as necessary for the given
general anesthesia, although in certain situations (e.g., in patient and pathology, and can be modified depending on the
patients with significant comorbidities), it can be done using location of the frontal sinus pathology, as noted by Batra et al.
local anesthesia and intravenous sedation. although this is typically not necessary [14].
Drape and prepare the patient as is usually done for an The soft tissues are gently dissected, sparing the supra-
endoscopic sinus procedure, with exposure of the entire trochlear and supraorbital neurovascular bundles until the
facial region including the forehead. If an image guidance frontal bone is exposed (Fig. 18.4).
204 R. Megía et al.

Fig. 18.3  Infrabrow incision 1.5 cm from the midline Fig. 18.5  Drilling at the orbital rim

Fig. 18.4  Gently dissection of the soft tissues until the frontal bone is Fig. 18.6  The osteotomy is enlarged as necessary with Kerrison
exposed rongeur

The periosteum is cut with a number 15 blade parallel

to the bony rim. Use a Freer or periosteal elevator to raise
the periosteum superiorly and inferiorly. The position of
the trephination is determined by the underlying pathology.
Image guidance trephination can specifically localize the tar-
get lesion, minimize the size of the skin incision and trephi-
nation and lower the risk of intracranial entry. A 3 or 4-mm
diamond bur is used to make an osteotomy at the orbital rim,
near the frontal sinus floor (Fig.  18.5). The anterior wall
contains vertical diploic bone, and entry through the ante-
rior wall is not recommended if the sinus is infected to avoid
the potential intracranial spread of infection or frontal bone Fig. 18.7  Megatrephination allows the osteotomy to be used for simul-
osteomyelitis [13]. taneous endoscopic visualization and surgical manipulation
Bone-cutting instruments (i.e., Kerrison rongeurs) can be
used to enlarge the opening if desired (Fig. 18.6). The oste-
otomy is enlarged as necessary to provide a surgical corridor The frontal trephination can be combined with an endo-
enabling endoscopic visualization with a 4-mm endoscope scopic frontal sinusotomy using an “above-and-below tech-
(0°, 30°, and 70° endoscopes) and surgical manipulation nique” [3] (Figs. 18.8, 18.9 and 18.10). If the frontal recess
simultaneously if needed. Endoscopes allow for visually anatomy is distorted, cannulating or irrigating with saline
inspecting the sinus and its drainage path. The final size with or without fluorescein through the trephine while visu-
and location of the osteotomy are dictated by the exposure alizing the recess endonasally may find the opening to the
required (Fig. 18.7). frontal sinus [15].
Through the trephination, perform dissection and instru- Utilizing the trephination osteotomy for endoscopic visu-
mentation based on the indication for the procedure. alization and surgical manipulation requires a larger opening.
18  Indication of Frontal Sinus Trephination Procedure 205

Fig. 18.8  Drawing showing “above-and-below technique”

Fig. 18.10  Endoscopic view through the nose and instrumentation

Fig. 18.9 Endoscopic view and instrumentation through the through the trephination
megatrephination
206 R. Megía et al.

A trephination of approx. 8 mm allows the osteotomy to be References

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Chron. 1884;3:235–8.
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has been discussed by Geltzeiler et al. who conclude that it is sinus. Otolaryngol Clin North Am. 2001;34:49–58.
not associated with cosmetic deformity [16]. 3. Hoffmann DF, May M.  Endoscopic frontal sinus surgery: frontal
A frontal sinus stent may be placed through the trephine trephine permits a “two-sided approach”. Oper Tech Otolaryngol
Head Neck Surg. 1991;2:257–61.
or endoscopically. A sutured catheter can be left to prevent 4. Patel AB, Cain RB, Lal D.  Contemporary applications of fron-
extrusion, which will allow postoperative rinsing of the fron- tal sinus trephination: a systematic review of the literature.
tal sinus [15]. Laryngoscope. 2015;125:2046–53.
The periosteum is approximated with absorbable sutures 5. Lawson W, Ho Y. Open frontal sinus surgery: a lost art. Otolaryngol
Clin North Am. 2016;49:1067–89.
and the skin incision is subsequently closed in layers. 6. Walgama E, Ahn C, Batra PS.  Surgical management of fron-
Figures 18.3, 18.4, 18.5, 18.6, 18.7, 18.9 and 18.10 show tal sinus inverted papilloma: a systematic review. Laryngoscope.
the different steps of the surgical procedure in a cadaver 2012;122:1205–9.
dissection. 7. Conger BT Jr, Illing E, Bush B, Woodworth BA. Management of
lateral frontal sinus pathology in the endoscopic era. Otolaryngol
Head Neck Surg. 2014;151:159–63.
8. Eloy JA, Marchiano E, Vázquez A. Extended endoscopic and open
18.7 Postoperative Tips sinus surgery for refractory chronic rhinosinusitis. Otolaryngol Clin
North Am. 2017;50(1):165–82.
9. Fry TL, Biggers WP, Fischer ND.  Frontal sinus trephination: a
If catheters have been left for postoperative irrigations, these new technique for office procedure. Laryngoscope. 1980;90(5 pt
are removed within 3–5  days. Sutures are removed within 1):838–41.
5–7 days. 10. Piltcher OB, Antunes M, Monteiro F, Schweiger C, Schatkin B. Is
No dressing is needed. there a reason for performing frontal sinus trephination at 1  cm
from midline? A tomographic study. Braz J Otorhinolaryngol.
Patients are evaluated in the clinic at the first and 2006;72:505–7.
third postoperative week. Additional visits are tailored 11. Iloreta A, Adappa N, Govindaraj S. Chapter 32-Frontal sinus treph-
to the degree of mucosal inflammation and underlying ination. Atlas of endoscopic sinus and skull base surgery. Second
pathology. edition. Philadelphia: Elsevier; 2019. p. 301–8.
12. Schneider J, Archilla A, Duncavage J.  Five ‘nontraditional’ tech-
A disadvantage of the frontal sinus trephination is exter- niques for use in patients with recalcitrant sinusitis. Curr Opin
nal scar formation or eyebrow alopecia, although if the Otolaryngol Head Neck Surg. 2013;21:39–44.
technique is done carefully, the aesthetic appearance is 13. Poetker DM, Loehrl TA, Toohill RJ.  Frontal sinus trephina-

adequate. tion for acute sinusitis. Oper Tech Otolaryngol Head Neck Surg.
2010;21:130–3.
Paresthesia due to supratrochlear or supraorbital nerve 14. Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephina-
injury, orbital injury, and injury to intracranial structures are tion and endoscopic frontal sinusotomy for management of com-
potential but avoidable complications [8]. plex frontal sinus pathology. Am J Rhinol. 2005;19(5):435–41.
Minor complications such as facial cellulitis and wound 15. Seiberling K, Jardeleza C, Wormald PJ.  Minitrephination of the
frontal sinus: indications and uses in today’s era of sinus surgery.
infection have been reported. Other rare but potential com- Am J Rhinol Allergy. 2009;23:229–31.
plications include penetration of the posterior table, cerebro- 16. Geltzeiler M, Mowery A, Detwiller KY, Mace JC, Smith TL. Frontal
spinal fluid leak and ophthalmologic injury (e.g., proptosis sinus “mega-trephination” in a tertiary rhinology practice. Int
and trochlear injury—superior oblique palsy) [14]. Forum Allergy Rhinol. 2019;9:1–7.
 The Place of Riedel–Mosher’s Procedure
in Contemporary Sinus Surgery 19
Giacomo Pietrobon, Francesco Bandi, Andrea Preti,
Paolo Castelnuovo, and Apostolos Karligkiotis

19.1 Introduction of removing the posterior wall and consequent exposition of

the brain meninges.
Endonasal endoscopic surgery represents the contemporary
gold standard approach for most inflammatory and tumoral
disorders of the frontal sinus. The endonasal endoscopic tech- 19.2 Indications
nique, in addition to the magnification of the operative field,
allows an anatomical approach to the drainage pathways of In current sinus and skull base surgery, Riedel–Mosher’s
the frontal sinus, avoiding unnatural routes or facial scars. procedure must follow strict indications, which can be sum-
Despite these premises, there are still conditions that pre- marized as follows [5]:
clude an exclusive endonasal endoscopic approach: compli-
cated rhinosinusitis, extensive benign tumors, malignancies, • Complications of acute or chronic frontal sinusitis, such
or trauma with fracture of the frontal sinus walls typically as osteomyelitis of anterior and posterior walls (with or
require a combined or external technique [1, 2]. without skin fistula).
Starting from the eighteenth century, literature reports • Extensive Pott’s puffy tumor (subperiosteal abscess of the
several transfacial/craniofacial techniques; however, many frontal bone) with associated common intracranial
are hampered by limited benefits and major complication complications.
risks, including death [3]. • Resorption of the frontal bone after a previous
In 1898, Riedel described the complete removal of the craniotomy.
anterior wall and floor of the frontal sinus in patients with • Malignant tumors of the frontal sinus.
osteomyelitis. Later, in 1933, Dr. Harry P.  Mosher intro- • Benign tumors with extensive involvement of anterior
duced the so-called frontal sinus ablation, extending Riedel’s and/or posterior walls of frontal sinus.
procedure to the posterior frontal wall [4]. This modification • Comminuted fractures of anterior/posterior walls.
does not add disfigurement to the patients and implements
indications of the original technique, which were quite lim- Chronic degenerative processes of the frontal bone,
ited. Of course, the approach should be more careful because namely chronic osteomyelitis, is usually the most frequent
indication for the procedure; it is caused by subacute infec-
tion or vascular impairment of the bony tissue, often devel-
oped sometime after a previous craniotomy. Acute
G. Pietrobon (*) · F. Bandi
suppurative complications of frontal sinusitis, such as Pott’s
Division of Otolaryngology and Head and Neck Surgery, IEO,
European Institute of Oncology, IRCCS, Milan, Italy puffy tumor, mandate immediate surgical treatment because
e-mail: [email protected]; [email protected] they may be associated with intracranial complications (e.g.,
A. Preti epidural/subdural/cerebral abscess) [6] and medical therapy
Department of Otorhinolaryngology, IRCCS Multimedica, or conservative surgery are ineffective. In fact, in these cases,
Milan, Italy the bone itself is affected; thus, antibiotic therapy cannot
P. Castelnuovo · A. Karligkiotis penetrate adequately and eradicate the infectious foci.
Division of Otorhinolaryngology, Department of Surgical Additionally, rehabilitation of the patency of the frontal
Specialties, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy
ostium through an endoscopic endonasal approach is insuf-
Head and Neck Surgery and Forensic Dissection Research Center ficient. Patients typically suffer recurrent headache, forehead
(HNS&FDRc), Department of Biotechnology and Life Sciences,
or supraorbital swelling and tenderness with purulent dis-
University of Insubria, Varese, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 207
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_19
208 G. Pietrobon et al.

charge intranasally or through cutaneous fistula. CT scan that form an hourglass shape. The cranial portion, named the
shows erosion or resorption of the sinus walls, with possible frontal infundibulum, is located in the inferior portion of the
bony sequestration or distortion of the cancellous bone [7– frontal sinus and forms a funnel directed inferiorly, posteri-
9]. In the case of long-standing inflammation, the disease orly, and medially. The waist of the hourglass is the frontal
may have spread through the diploic veins of Breschet and sinus ostium located posteromedially in the sinus. The cau-
be evident not clinically but only microscopically [4]. dal portion of the hourglass is formed by the frontal recess, a
Therefore, complete ablation provides a greater chance of narrow cleft between the anterior ethmoid complex posteri-
cure than a partial procedure (i.e., classic Riedel technique). orly and a thick caudal extension of the anterior frontal wall,
In case of the rare malignant tumors of the frontal sinus the so-called frontal beak [17].
[10], resection must encompass the walls unilaterally or The scalp is made up of five soft tissue layers that cover
bilaterally. Depending on the extension of the disease, it may the cranium: the skin, connective tissue layer, galea aponeu-
extend further to include the orbital floor or adjacent bony rotica, loose areolar connective tissue, and the pericranium.
components of the skull. Preoperative imaging and intraop- The galea aponeurotica is a continuation of the occipitofron-
erative frozen section are necessary to modulate the resec- tal muscle: the frontalis belly anteriorly inserts into the supe-
tion. These cancers usually present in advanced stages and rior orbicularis oculi at the level of the eyebrow while the
bear a poor prognosis, so the timing of reconstruction is a occipitalis muscle posteriorly inserts at the mastoid and
matter of debate. superior nuchal lines. The occipitofrontal muscle pulls the
A few benign fibrous-osseous tumors of the frontal sinus scalp back and elevates the eyebrows. The vascular support
may cause subtotal substitution of the whole bone; thus, they of the scalp is mostly provided by the branches of the exter-
mandate removal of both anterior and posterior walls nal carotid artery. The superficial temporal artery, after pass-
[11–13]. ing over the posterior aspect of the zygomatic arch, divides
When the sinus walls are shattered and bony fragments into frontal and parietal branches.
cannot be wired, conservation is not possible and ablation is The scalp is also vascularized by branches of the internal
indicated [14]. Additionally, removing the frontal bone may carotid artery: the ophthalmic artery divides into supraorbital
be necessary to decompress the brain after the trauma, so and supratrochlear branches, which exit the skull through the
reconstruction with fragments is even more unrealistic [15]. supraorbital foramen and anastomose with their contralateral
arteries and with rami of the superficial temporal artery to
vascularize the anterior portion of the scalp. The scalp drains
19.3 Schematic Description (Anatomy— into superficial and deep venous systems. The supraorbital
Expected Result) and supratrochlear veins drain the superficial scalp anteriorly
while the superficial temporal, occipital, posterior auricular
The frontal bone can be subdivided into a vertical and a hori- drain the superficial scalp posteriorly. The pterygoid venous
zontal segment. The vertical or squamous portion constitutes plexus is responsible for draining the deep scalp [18]
the supporting bone of the forehead and contains the frontal (Fig. 19.1).
sinus between its anterior and posterior table. The anterior Special attention should also be paid to the facial nerve
plate is thicker and encloses cancellous bone between its cor- temporal branch: this nerve divides into anterior and poste-
tical laminae, while the posterior plate is thinner and is rior rami after piercing the parotid-masseteric fascia below
directly in contact with the dura mater. The horizontal seg- the zygomatic arch. These rami cross the arch in the subcu-
ment forms the roof of the orbits and articulates with the taneous tissue and above the arch lie in the subgaleal space.
ethmoid bone to form the roof of the nasal cavity, the frontal The more anterior branches supply the frontal belly of
recess, and the anterior skull base. In most subjects, the fron- occipitofrontalis, orbicularis oculi and corrugator, and join
tal sinuses are asymmetrical cell pairs separated by a central the supraorbital and lacrimal branches of the ophthalmic
interfrontal septum and are variously pneumatized. In adults, nerve [19].
the average size of the sinus is 24.3 mm in height, 29.0 mm The frontal nerve is the largest branch of the ophthalmic
in width, and 20.5 mm in depth [16]. In some cases, when the nerve. It exits through the superior rim of the orbit on levator
true interfrontal septum is markedly lateralized, a vertical palpebrae superioris and along this course it divides into the
lamina may be identified protruding from the posterior wall. supraorbital and supratrochlear nerves. The supraorbital
This vertical plate, also called the olfactory crest, represents nerve, the larger of the two terminal branches of the frontal
the anterior bony continuation of the olfactory fossa and, if nerve, continues forward along the levator palpebrae superi-
mistaken for the interfrontal septum, can lead to the forma- oris until it leaves the orbit through the supraorbital recess or
tion of a cerebrospinal fluid (CSF) leak [17]. The frontal foramen. It emerges at the forehead and supplies the skin and
sinus drainage pathway consists of three different portions conjunctiva covering the upper eyelid and the skin of the
19  The Place of Riedel–Mosher’s Procedure in Contemporary Sinus Surgery 209

a 19.4 Preoperative Tips (Individual Risk

Factors, Radiology, Instrumentation)

In the approach to extensive frontal sinus diseases, certain

caveats must be considered regarding both the patient’s gen-
eral status and the type of pathology involved. A careful pre-
operative anesthetic evaluation should take into account
controlled hypotension during anesthesia and alterations in
general status when manipulating the central nervous sys-
tem. Cooperation with the neurosurgeon is strictly recom-
mended, especially when surgery on the brain parenchyma
or reconstruction of the dura is planned.
In case of malignant or benign tumor, the preoperative
planning should include CT and MRI with and without con-
trast to assess the boundaries of the disease and its extension
to bone or soft tissues. An endonasal endoscopic or open
b
biopsy should be performed in order to prevent inappropriate
surgery on lesions that can potentially be addressed with
nonsurgical treatments.
A comprehensive evaluation by CT and MRI is strongly
recommended in all cases of external approach to the frontal
sinus since previous treatments, trauma, or inflammatory
diseases can distort the local anatomy with the development
of dural herniation which, if undetected, can lead to an iatro-
genic brain injury or to a CSF leak.
Knowing the boundaries of the frontal sinus is a key point
in external frontal access. Prior to surgery, an autoclave tem-
c plate of the frontal sinus outline is obtained from a 6-ft
Caldwell view cranial X-ray or, as an alternative, a magnetic
navigation system is set up using the preoperative CT scan,
as described by Volpi et al. [21].

Necessary instrumentation
–– No. 10 or 15 scalpel blades.
–– Bipolar cautery and monopolar scalpel.
–– Raney clips.
–– Fine suction device.
–– Periosteal elevator or Freer dissector.
–– Sagittal saw blade.
Fig. 19.1 (a) Pericranium (P), galeal flap (single black asterisk),
superficial temporal artery dividing into its frontal and parietal branches
–– Hammer and chisels.
(black thick arrow), superficial temporalis fascia (double black aster- –– 4 and 5 mm round diamond bur.
isks), subgaleal fat pad (black arrowheads). (b) Nasion (N), pericra- –– Kerrison rongeur.
nium (P), zygomatic arch (ZA), temporalis muscle (TM), galeal flap –– Silk sutures, Surgicel (Johnson & Johnson Medical,
(single black asterisk), deep branches of supratrochlear artery (black
thin arrow), deep branches of supraorbital artery (black dotted arrow).
Arlington, TX, USA), Fibrin Glue.
(c) Pericranium (P), galeal flap (single black asterisk), superficial tem- –– Metal mini plates with suitable screws and screwdriver.
poral artery (black thick arrow), superficial temporalis fascia (double –– Frontal implant (metal, plastic, ceramic, or other materi-
black asterisks), deep temporalis fascia (single red asterisk), interfascial als defined preoperatively).
fat pad (red arrowheads)

forehead and scalp. The supratrochlear nerve runs medially 19.5 Pearls and Potential Pitfalls
over the trochlea to the tendon of the superior oblique. It
gives a descending branch to the infratrochlear nerve and As the first step of the surgical procedure, the scalp incision
ascends the forehead to supply the skin and conjunctiva cov- must be made with a cold blade and possibly in a vertical
ering the upper eyelid, and the skin of the forehead [20]. direction without undermining the cutting line to sacrifice
210 G. Pietrobon et al.

Fig. 19.2  The coronal incision is outlined on the scalp, keeping the
midline as reference. The black line indicates the hair line. Note the
anterior peak of the incision in the midline

the minimum number of hair follicles and limit the postsur-

gical alopecia. The incision is also made on a coronal plane
approximately 5 cm behind the hairline to hide the scar. An
anterior peak also aids in the approximation of the scalp flaps
during closure (Fig. 19.2).
When harvesting the flap in a subgaleal plane, it is impor-
tant to preserve the supraorbital and supratrochlear nerve and
vessels: this is obtained by keeping the flap pedicled inferi-
orly at the supraorbital rim, without extending the dissection
further and exposing the abovementioned structures. It is
also crucial to save the frontal division of the facial nerve,
running inside the subgaleal fat pad between the temporopa-
rietal fascia (TPF) and the temporalis muscle fascia (TMF).
When approaching the lateral region of the nerve, the sur-
geon should avoid dissection in the fat and rather incise the
TMF and follow the plane beneath it [22]. Fig. 19.3  The frontal osteotomy is performed with a saw and chisels
oblique to the bone
Some authors recommend using a pericranial-frontalis
muscle flap rather than a pericranial flap, even in patients
with skin fistula, as pericranial flaps may not retain a After removing the anterior and posterior frontal walls,
sufficient blood supply after previous operations and
­ there should be no mucosal residue above the reconstructed
­infections [23]. frontal sinus floor to prevent mucocele. This can be achieved
The most critical phase of the procedure is the opening of either by extirpating the mucosal lining completely and drill-
the frontal sinus through the removal of the anterior table. ing the underlying bone or by inverting the residual mucosa
During this step, it is essential to have preoperative guidance of the frontal outflow tract into the nose [23].
of the sinus limits through an X-ray or CT guided neuronavi- Frontal restoration should be deferred, and it needs care-
gation. The use of saws or chisels in accessing the sinus ful preoperative planning, particularly in terms of biomate-
should provide an oblique and nonvertical plane of entry to rial to fit the defect. Several options are available, each with
prevent an uncontrolled rupture of the posterior wall and a pros and cons [24]: the final choice depends on clinical fea-
potential injury to the dura mater and cerebral parenchyma tures, of course, but also on costs and supply availability
(Fig. 19.3). (Fig. 19.4).
19  The Place of Riedel–Mosher’s Procedure in Contemporary Sinus Surgery 211

a b

Fig. 19.4  Reconstruction of the anterior plate of the frontal bone with a titanium plate (a) or polymethylmethacrylate (PMMA) plate (b)

Fig. 19.5  Harvesting of the pericranial flap

19.6 Surgical Procedure Step by Step cranial flap is then created and kept pedicled caudally at the
bone (Fig. 19.5).
19.6.1 Scalp and Pericranial Flap

Surgery is performed under hypotensive general anesthesia,

in a slight anti-Trendelenburg position. Local anesthesia can 19.6.2 Anterior Frontal Wall Removal
be injected to decrease the bleeding. A coronal incision is
made from ear to ear, and Raney clips are applied to improve The shape of the frontal sinus is outlined by the template or
hemostasis. The incision is carried down to the subgaleal by the magnetic navigation system (Fig. 19.6). The anterior
plane as far as the loose areolar tissue, and the scalp is pulled wall of the frontal sinus is opened with the sagittal saw or
down caudally on both sides through blunt dissection until drilled bilaterally as far as the supraorbital ridge while pre-
the supraorbital rims and the nasion. A large periosteal/peri- serving a bony lid to hinge the periosteal flap. The sinus is
212 G. Pietrobon et al.

Fig. 19.6  Outlining of the frontal sinus contour with the aid of a magnetic navigation system

exposed as lateral as the supraorbital cells, and the bony bor- modified on the basis of possible cultural exams. The drain is
ders are smoothed with a diamond bur and/or Kerrison usually removed 2 days after surgery. If the surgical proce-
rongeur. dure entails dural repair, patients resume orthostatism gradu-
ally and start walking again on the fifth postoperative day.
They are also advised to avoid physical exertion and head
19.6.3 Posterior Frontal Wall and Frontal Floor bending, to take stool softeners, antihistaminic, and sedative
Removal drugs in case of constipation, sneezing, and coughing,
respectively. Clinical and radiological control is scheduled
The diseased tissue is removed as far as the posterior wall of depending on the disease treated.
the frontal sinus (pwFS), which is thinned, fractured, and
gradually removed to expose the dura mater. Crista galli is
resected, and a wide Draf III sinusotomy is realized (Fig. 19.7). 19.7.1 Reconstruction
In case of accidental damage, the dura may be sutured. Finally,
the pericranial/pericranial-frontalis muscle flap is everted to Cranioplasty is necessary to restore the frontal contour, but
cover the Draf III sinusotomy and the exposed dura of the its timing needs to be properly evaluated to avoid additional
anterior cranial fossa (Fig. 19.8). The nasal fossae need to be complications. Before scheduling surgery, the patient’s
separated completely from the frontal region. conditions have to be assessed: beyond clinical examina-
tion to exclude overt infective foci, negative inflammatory
markers (white blood count, C-reactive protein, erythrocyte
19.6.4 Pericranial Reconstruction and Closure sedimentation rate, procalcitonin) and CT scan are required.
Various materials are available: ceramic and PMMA pro-
The pericranial flap is stabilized to the dura with stitches, vide optimal results in terms of both aesthetic and function
Surgicel and fibrin glue. In the end, the scalp is flipped back because they are biocompatible, light- and heat-insensitive
and sutured with single stitches or staples. In addition, a and may induce bone growth [25]. Depending on the mate-
drain is inserted. rial used to reconstruct, the template may be preformed,
custom-made, based on the postresection imaging of the
patient (CT scan), or, conversely, it may be modeled during
19.7 Postoperative Tips surgery, following the contour of the resulting defect. In
particular, the former technique is founded on a 3D com-
Intravenous antibiotic coverage with ampicillin/sulbactam is puted reconstruction of the defect, guided by radiologic
administered according to preoperative condition and intra- imaging (computed-aided design, CAD), and on the subse-
operative findings. If an infection is present at the time of quent realization of a three-­dimensional implant through
surgery, a full course is indicated. Antibiotic therapy may be additive processes, such as stereolithography (SLA), selec-
19  The Place of Riedel–Mosher’s Procedure in Contemporary Sinus Surgery 213

a b

c d

Fig. 19.7  Drilling of the posterior wall of the frontal sinus (a, b) until dural exposition (c, d) and removal of crista galli (e)

tive laser sintering (SLS) or fused deposition modeling The surgical approach is similar to the ablation phase but,
(FDM), thanks to the so-called computer-aided manufac- at this time, harvesting of the scalp flap must be carried out
turing (CAM). This technique allows for a very precise very carefully because of the higher risk of dural damage
reconstruction, but widening or correction of the bony (Fig. 19.9). Once the bony edges are exposed and possibly
defect must obviously be avoided. smoothed, the premolded implant is fixed with metallic
Autologous calvarial bone is not a valid option for the miniplates and screws. A drain is inserted and kept in place
morbidity of the donor site and the significant rate of later for 48 h. A CT-scan is planned postoperatively to assess the
complications, mainly infection or resorption [26, 27]. correct positioning of the implant (Fig. 19.10).
214 G. Pietrobon et al.

a b

c d

Fig. 19.8  Once the dural breaches are repaired (a), the pericranial flap is placed back to cover the Draf type III sinusotomy and the exposed dura
mater (b); it is then stitched to the dura (c), and stabilized with fibrin glue (d) and hemostatic gauze (e)

Fig. 19.9  Harvesting of the scalp flap ahead of hemifrontal cranioplasty. Note the adherence between the galea (arrow) and the underlying dura
mater (asterisk)
19  The Place of Riedel–Mosher’s Procedure in Contemporary Sinus Surgery 215

a b

c d

Fig. 19.10  Preoperative (a, b) and postoperative (c, d) CT-scans of a patient submitted to right hemifrontal cranioplasty with titanium plate (same
patient of Fig. 19.4a)

4. Mosher HP, Judd DK. An analysis of seven cases of osteomyelitis

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 The Importance of Frontal Sinus
Surgery in Craniofacial Resection. 20
Endoscopic, Open, and Combined
Approaches

José Luis Llorente, Fernando López, María Costales,

Patricia García-Cabo, and Carlos Suarez

20.1 Introduction resection of accessible portions of the tumor from below

with a bifrontal craniotomy for maximal resection of intra-
Craniofacial approaches are a group of surgical approaches cranial pathology. A CN approach would be required, par-
designed to resect tumors that develop in the surrounding ticularly if an orbital exenteration is indicated.
area of the cribriform plate [1, 2]. Sometimes, these are sino-
nasal tumors that grow into the endocranium (anterior fossa).
Less often these are endocranial tumors that progress to the 20.3 Anatomy
sinonasal area.
In any case, these approaches have in common that their In this chapter, we will describe the different options that
epicenter is the frontal sinus and its morphology can influ- exist in the frontal approaches, based mainly on two prem-
ence the type of approach to perform. ises: the frontal sinus anatomy and the tumor invasion. An
important preoperative issue is to precisely know the ana-
tomical morphology of the frontal sinuses since there may be
20.2 Indications important differences between individuals. Even between
the frontal sinus on one side and the other of the same
To systematize, we could classify the craniofacial approaches person.
into: The diagnosis of frontal pathology (including tumors)
Open transfrontal craniofacial approach (with its vari- frequently cannot be made by the presenting signs and symp-
ants). This approach is mainly indicated when there is an toms. In these cases, CT scanning and MRI are essential in
acceptable development of frontal sinus pneumatization and the preoperative examination. Basically, the CT will help us
when the tumor has a significant invasion of the dura or brain to know the integrity, shape, septation, and aerial develop-
or has a lateral frontal invasion. ment of the frontal sinuses. MRI allows us to identify the soft
Craniofacial endoscopic approach. Nowadays, endo- tissues of tumors and their possible relationship with adja-
scopic craniofacial resection can be considered a safe tech- cent structures such as the brain or the orbit.
nique from an oncological point of view and it generates
fewer sequelae than traditional open approaches [3]. This
could be contraindicated when the tumor has a significant 20.4 Preoperative Tips
invasion of the brain, when it has a lateral frontal invasion or
when a special reconstructive method is necessary. As the frontal sinus is difficult, if not impossible, to explore,
Combined cranionasal approach. The combined or cra- it is necessary to have an exact preoperative knowledge of
nionasal (CN) approach incorporates endonasal endoscopic the anatomy and the extent of the underlying disease. We
will basically achieve this with CT and MRI; thus, both these
complementary tests are considered necessary for a correct
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_20]. preoperative surgical approach.

J. L. Llorente (*) · F. López · M. Costales · P. García-Cabo

C. Suarez
Servicio ORL, Hospital Universitario Central de Asturias,
Oviedo, Asturias, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 217
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_20
218 J. L. Llorente et al.

20.4.1 Instrumentation 20.6 Surgical Procedure Step by Step

For external approaches to the frontal sinus (craniofacial 20.6.1 Open Transfrontal Craniofacial
resection and its variants), no specific instrumentation is Approach
required. We only need to have well-sharpened saws, drills
for bone milling (posterior wall of the frontal sinus) and 2 or In the standard procedure [4–6], the cranial approach is per-
3 microplates to fix the bone fragment at the end of the formed through a coronal incision and a paranasal approach
operation. in the majority of the cases (Video 20.1). A relative pneuma-
In most cases, a transfrontal craniectomy is performed. In tization of the frontal sinus is necessary to allow us to remove
the few cases of frontal sinus agenesia only a small craniec- the anterior bony wall of the sinus to replace it later, if not
tomy is needed. Therefore, it is not necessary to use brain affected. Such approach angle, more tangential, prevents the
retractors or specific neurosurgical instruments. In cases of retraction of the frontal lobes with an adequate surgical expo-
endoscopic approaches, only the standard material of nasal sure. In the absence of pneumatization of the frontal sinus, a
endoscopic surgery and a septorhinoplasty is necessary. In small craniectomy must be necessary with a minimal or not at
addition, it is advisable to have an endonasal bur of enough all retraction of the brain. In the facial approach, adequate
length (>18 cm) for drilling the frontal sinus, the roof of the exposure is achieved with a paranasal incision and removing
ethmoid and the rostrum of the sphenoid. the ascending process of the maxillary. We also can mobilize
the entire nasal complex which is swung to the contralateral
side in bilateral tumors (subcranial approach) [7].
20.5 Pearls and Potential Pitfalls Most often, the skin incisions are coronal and paranasal,
which allows the tumor to be approached from above and below.
–– An anatomical knowledge of the frontal area is crucial to The patient is positioned in a supine position without any type
design the most appropriate approach in terms of acces- of head fixation. A bicoronal incision is then made (Fig. 20.1).
sibility with the fewest possible sequelae. The cutaneous frontal flap is elevated in the subcutaneous
–– During the surgery, a delicate and precise handling of the plane anterior to the submucosal aponeurotic system (SMAS)
tissues is important, using saws and burs in perfect condi- fascia without cutting the calvarial periosteum (pericra-
tion to avoid tears and lacerations. nium). The scalp flap is brought down low over the orbits and
–– Either with endoscopic or open approaches, the key is the nasion, preserving the supraorbital and supratrochlear
perfect isolation of a septic cavity like the nasal fossa neurovascular bundles. Pericranium is elevated as a separate
from an aseptic cavity like the brain. layer, usually designed in a rectangular fashion (Fig. 20.2)
–– Inert tissues such as fascia lata can be used in the repair, with the base in the supraorbital area and its tip at the level of
but it is advisable to keep the surrounding tissues as the bicoronal scalp incision. Its length from the supraorbital
healthy, vascularized and intact as possible. When possi- level is approximately 10 cm. Occasionally additional lateral
ble, it is very favorable to use vascularized flaps (e.g.,
pericranium) because pedicled nasal flaps can rarely be
used for oncological reasons.
–– If the periorbit is preserved, it is not necessary to repair
the orbit walls, if the superexternal and the inferior exter-
nal third (lateral to V2) are maintained.
–– Adequate nasal packing usually prevents bleeding and the
formation of emphysema.
–– The closure of the dura mater and brain is usually suffi-
cient with two layers, preferably intradural and
intracranial.
–– In case of opening of the dura mater, a lumbar drain is
usually not recommended due to the danger of siphoning
effect and the consequent pneumocephalus.
–– In the case of open surgeries, the fixation of the bone is
usually done with 2 or 3 microplates since it is an area
without mobility; therefore, the stabilization of bone frag-
ments is not usually a problem. Fig. 20.1  Coronal and paranasal incision
20  The Importance of Frontal Sinus Surgery in Craniofacial Resection. Endoscopic, Open, and Combined Approaches 219

Fig. 20.2  Pericranial flap raised from scalp flap Fig. 20.4  Lifting of the anterior osteoplastic flap attached to the
periosteum

Fig. 20.3  Frontal sinus profile marked

Fig. 20.5  Drilling the posterior wall of the frontal sinus and removing
all the frontal sinus mucosa
rotation of the flap is necessary, so the sacrifice of the contra-
lateral supraorbital pedicle permits further rotation.
Using an electrosurgical scalpel, the profile of the frontal includes the anterior wall of the frontal sinus, orbital ridges,
sinus is outlined over the bone using a template of a Caldwell part of the roof of the orbit and nasal bones, which is known
sinus radiography or with a navigator (Fig. 20.3). By means as the subcranial approach. The created osteoplastic flap
of an oscillating saw, a bevel cut is made through the previ- must be replaced later at the end of the procedure with micro-
ously marked line until it enters the frontal sinus while avoid- plates. These approaches are indicated if there is a notable
ing injury to the posterior frontal wall and dura mater pneumatization of the frontal sinus and a bilateral invasion of
(Fig. 20.4). In some cases, we can leave the anterior osteo- the cribriform plate by the tumor. Alternatively, if there is a
plastic flap attached to the periosteum or remove it com- lack of pneumatization of the frontal sinus, a small quadran-
pletely including or not nasal bones that must be replaced gular supraorbital craniectomy can be performed.
later at the end of the procedure. After the frontal posterior wall bone drilling, the dura is
Subsequently, under the microscope, the drilling of the dissected and elevated from the floor of the anterior fossa
posterior frontal wall as well as the frontal sinus floor and the (Fig.  20.6). To perform the dural elevation over the cribri-
meticulous removal of the entire mucosa of the frontal sinus form plate it is necessary to cut the fila olfactoria, if not
will allow us to get to work on the dura and the tumor involved by the tumor, to reach the planum sphenoidale.
(Fig. 20.5). Total mucosa removal of the frontal sinus avoids If the dura is affected by the tumor, we must go intradural
remucosalization or deferred mucoceles. and the tumor must be resected with adequate free margin. It
In the case of large or bilateral tumors requiring extensive is not necessary to have any (or minimally) type of brain
exposure, a monobloc osteotomy may be performed which retraction. If there is a wide cerebral infiltration, we need a
220 J. L. Llorente et al.

Fig. 20.8  Intranasal exposure and resection of the tumor

Fig. 20.6  Posterior wall of the frontal sinus already drilled and dura-
mater exposed

Fig. 20.7  Lateral rhinotomy incision

Fig. 20.9  Repair of the dura with fascia lata (bank) along the anterior
fossa floor

wider resection. However, due to the bad prognosis (often

preoperatively identified by CT or MRI) we can consider Once the tumor has been removed, we must repair the
other types of therapy such as chemoradiation. defect to reestablish the extracranial (nasal cavities) and
Once the tumor is freed and isolated from the brain, the intracranial separation. When a considerable segment of
floor of the anterior cranial fossa is removed intra or extradu- dura has been removed, the most appropriate method of
ral and osteotomies are performed through the planum sphe- reconstruction is to replace it with a cryopreserved fascia lata
noidale sinus, medial part of the orbital ceilings, and anterior graft in two layers (in and overlay) (Fig. 20.9) and the bony
to the crista galli. flap is fixed with microplates (Figs. 20.10 and 20.11). In the
In some cases, the tumor can be delivered upward through case of a wide removal of the basal dura, it is preferable to
the frontal sinus (in piecemeal) or downward through facial use a pericranium vascularized flap to isolate both cavities.
incision. When the tumor has an important sinonasal compo- Otherwise, the pericranium is replaced and sutured
nent, a lateral rhinotomy incision should be made (Fig. 20.7) (Fig. 20.12).
followed by an osteotomy of the ascending maxillary pro- In the case of tumors that invade deeply the orbit and the
cess. A dacryocystorhinostomy must also be performed. This cranial base, it is necessary to add an orbital exenteration to
way, we can expose the tumor and resect it completely the craniofacial approach. This results in a large cavity that
(Fig. 20.8) including a medial maxillectomy, lamina papyra- should be filled with a temporal muscle flap or a microvascu-
cea, ethmoid, pterygoid plate, rostrum, septum or inferior lar free flap (anterior thighs, parascapular, latissimus dorsi or
turbinate, when necessary. rectus abdominis) [8].
20  The Importance of Frontal Sinus Surgery in Craniofacial Resection. Endoscopic, Open, and Combined Approaches 221

Fig. 20.12  Repositioning of the pericranium flap (not used in this case
for reconstruction of the anterior fossa floor)

Fig. 20.10  Repositioning the osteoplastic frontal flap

Fig. 20.11  Fixing the osteoplastic flap with microplates

Finally, the nasal cavity is packed and the lateral parana-

sal (Figs. 20.13 and 20.14) and coronal incisions (Fig. 20.15)
are sutured in two layers. Fig. 20.13  Paranasal wound sutured
222 J. L. Llorente et al.

to orbit and from frontal sinus to the planum sphenoidale),

the tumor origin is exposed and the resection can begin
(Video 20.2).
Preoperatively, pneumatization of the frontal sinus should
be considered. If there is no pneumatization or it is very
small, the approach can be performed without problem
unless there is a wide infiltration of the bone in the anterior
frontal wall which may contraindicate this approach.
In case of normal or wide frontal sinus pneumatization, a
Draf III should be carried out prior to the intracranial
approach (Fig.  20.16). This allows us wide control of the
frontal sinus and thus dissection and resection progress from
anterior to posterior.
The cribriform plate is removed, starting with a horizontal
osteotomy (with a drill or chisel) behind the internal table of
the frontal sinus and continues with lateral osteotomies par-
Fig. 20.14  Immediate postoperative allel to the superomedial orbital wall. Again, another hori-
zontal osteotomy is performed at the planum sphenoidale
level.
These maneuvers make it possible to resect a rectangle
that includes tumor origin and the adjacent structures, such
as nasal septum, cribriform plate, and planum sphenoidale.
The Crista Galli is fractured and resected individually.
Dural incisions, which coincide with the osteotomies
described above, facilitate tumor removal with adequate con-
trol of its margins and origin, except if brain infiltration is
present (Fig.  20.17). For reconstruction, we usually use a
double-layer technique (intra and extra dural) with heterolo-
gous fascia lata obtained from the tissue bank (Fig. 20.18).
The use of Surgicel® (Original Absorbable Hemostat,
Ethicon, Inc., USA) helps to adapt the fascia to the dural
defect.

Fig. 20.15  Coronal incision sutured

20.6.2 Craniofacial Endoscopic Approach

Over the last two decades, there have been significant

advances in endoscopic skull-based surgery. Due to the pro-
gressive application of endoscopic techniques in the treat-
ment of benign and malignant diseases in the skull base,
endoscopic surgery has become, in certain situations, a stan-
dard surgical approach for inflammatory and sinonasal
tumors [9].
When a complete craniofacial endoscopic technique is Fig. 20.16  Endoscopic image of a Draf type III approach to the frontal
performed, after broadly exposing the skull base (from orbit sinuses
20  The Importance of Frontal Sinus Surgery in Craniofacial Resection. Endoscopic, Open, and Combined Approaches 223

20.7 Postoperative Tips

Adequate coverage and dosage of analgesia and antibiotics is

necessary, starting during the intervention (preferably
cefazolin or amoxicillin with clavulanic acid).
Possible appearance of complications such as bleeding,
emphysema, and especially meningitis or ocular abnormali-
ties should be monitored and identified early in case they
occur.
Nasal packing is almost always recommended for at least
2–3  days. Suitable nasal irrigation and antibiotic ointment
reduce crusting.

References
1. Donald PJ, Gluckman JL, Rice DH. The sinuses. New York: Raven
Fig. 20.17  Endoscopic view after performing an endoscopic craniofa- Press; 1994. p. 423–94.
cial resection of an ethmoid tumor 2. Lund VJ, Stammberger H, Nicolai P, et al. European position paper
on endoscopic management of tumours of the nose, paranasal
sinuses and skull base. Rhinol Suppl. 2010;22:1–143.
3. Nicolai P, Castelnuovo P, Bolzoni Villaret A. Endoscopic resection
of sinonasal malignancies. Curr Oncol Rep. 2011;13(2):138–44.
4. Sekhar LN, Janecka IP. Surgery of cranial base tumors. New York:
Raven Press; 1993. p. 147–56.
5. Suarez C, Maldonado M, Llorente JL.  Abordajes anteriores de la
base del cráneo en los tumores de senos. En: Otorrinolaringología
1999. Libro Del Año. Madrid: Saned; 1999. p. 49–84.
6. Suarez C, Llorente JL, De Fernandez Leon R, Maseda E, Lopez
A.  Prognostic factors in sinonasal tumors involving the anterior
skull base. Head Neck. 2004;26(2):136–44.
7. Raveh J, Ladrach K, Speiser M. The subcranial approach for fronto-­
orbital and anteroposterior skull base tumors. Arch Otolaryngol
Head Neck Surg. 1993;119:385–93.
8. Llorente JL, Lopez F, Camporro D, Fueyo A, Rial JC, Fernández de
León R, Suarez C.  Outcomes following microvascular free tissue
transfer in reconstructing skull base defects. J Neurol Surg Part B
Skull Base. 2013;74(5):324–30.
9. Llorente JL, López F, Suárez V, Costales M, Moreno C, Suárez
C.  Endoscopic craniofacial resection. Indications and technical
Fig. 20.18  Intradural placement of a fascia lata layer (with Surgicel®) aspects. Acta Otorrinolaringol Esp. 2012;63(6):413–20.
with a watertight closure of the dura

20.6.3 Combined Cranionasal Approach

In selected cases a combined approach can be performed,

with an open coronal approach and an endoscopic nasal
approach, mainly in order to avoid facial scars.
 Frontal Sinus Tumours
21
Cristóbal Langdon and Claudio Arancibia

21.1 Introduction Treatment modalities for frontal sinus osteomas will be

discussed in Chap. 26. Generally, small and asymptomatic
Frontal sinus lesions can be classified into benign or malig- osteomas can be followed with a CT scan [5]. Osteomas in
nant lesions. In the first group it is worth mentioning: oste- symptomatic patients, with rapid growth rate (>5 mm year),
oma, mucocele, fibrous dysplasia, ossifying fibroma, and obstruction of the frontal recess or more than 50% occupa-
inverted papilloma. Malignant tumours of the frontal sinus tion of the frontal sinus should be considered for surgery.
are rare and include squamous cell carcinoma, adenocarci-
noma, sinonasal undifferentiated carcinoma, sinonasal neu-
roendocrine carcinoma, esthesioneuroblastoma, sarcoma, 21.2.2 Mucocele
adenoid cystic carcinoma, and non-Hodgkin lymphoma.
For a detailed description of the surgical technique, see ·Mucoceles are benign cystic lesions, mucus-filled and lined
Chaps. 15, 17, 19, and 20. with respiratory epithelium, with capacity to erode and
expand into surrounding structures. The most frequent loca-
tions are frontal and frontoethmoidal, followed by maxillary
21.2 Benign Lesions of the Frontal Sinus and sphenoidal [6]. Primary mucoceles occur without any
prior history, while secondary mucoceles usually have a his-
21.2.1 Osteoma tory of trauma or previous surgery. Secondary mucoceles can
be latent as long as 18 years between the cause and the diag-
·Osteoma is the most frequent benign tumor of the paranasal nosis, this emphasizes the importance of long-term follow-
sinuses, with a reported incidence of 0.5–3% in the general ­up after sinus surgery. Symptoms include headaches, facial
population [1]. It is mostly found in men in the third and pain, congestion, and nasal drainage [6]. CT shows an
fourth decade of life [2]. They are slow growing, and are expansile, homogeneous, non-rim enhancing (unless associ-
more frequently found in the frontal sinus, though a recent ated with mucopyocele) sinus mass, with bone remodeling
review suggests that the ethmoidal origin is the more fre- [7]. Magnetic resonance imaging (MRI) depends on fluid
quent location [3]. content, high water content mucoceles have low intensity on
They are generally asymptomatic, and can be found as an T1 and hyperintensity in T2. With water absorption and
incidental radiologic finding [4]. The most common symp- increased protein concentration, they can become iso or
tom is frontal headache or facial pain; this occurs when oste- hyperintense in T1 [8]. The preferred surgical approach is
omas obstruct the drainage pathways or compress endoscopic marsupialization [9, 10]. More information on
surrounding structures. Osteomas can be isolated or as a fea- the treatment of mucocele can be found in Chap. 25.
ture of Gardner’s syndrome, which includes multiples osteo-
mas, colonic polyposis and soft tissue tumours [4]. On
computed tomography (CT) scans, they appear as a 21.2.3 Fibro-Osseus Lesions
radiodense lesion of the paranasal cavities.
Fibro-osseus lesions that can affect the frontal bone include
fibrous dysplasia (FD) and ossifying fibroma (OF). FD is a
skeletal disease characterized by the substitution of bone
C. Langdon (*) · C. Arancibia marrow with fibrous tissue. It can compromise one (mono-
Rhinology and Skull Base Unit, Otorhinolaryngology Department,
stotic) or multiple bones (polyostotic). Though maxillary
Hospital Clinic, IDIBAPS, Ciberes, Barcelona, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 225
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_21
226 C. Langdon and C. Arancibia

bone and mandible are the most commonly affected cranio- eral lesion. Bone erosion is frequent, and there can be focal
facial bones [11], frontal FD has also been described. hyperostosis, which has been suggested as the implantation
Treatment is usually conservative with regular follow-up, site of the tumor (Fig. 21.2) [17]. The treatment of IP is sur-
while surgery is indicated in case of complication (visual gery, with the main objective of achieving a complete resec-
impairment, cosmetic deformity). Also, bisphosphonates, tion and drilling of the insertion of the tumor (see Chap. 27).
like pamidronic and alendronic acids, have shown a reduc- MRI shows hypointense signal on T1 with intense contrast
tion in bone pain and turnover [12]. OF is a benign fibro-­ uptake and hypo or isointense signal in T2. A cerebriform
osseous neoplasm that affects the jaws and the craniofacial aspect is seen in both T1 and T2 [18].
skeleton. It can be divided into conventional OF and juvenile
OF (JOF). JOF can also be subdivided in juvenile trabecular
OF and juvenile psammomatoid OF, the first has predilection
for maxilla and the last for paranasal sinuses. JOF is usually
asymptomatic and treatment is surgical, including enucle-
ation, curettage, or a combination of them [13].

21.2.4 Inverted Papilloma

Inverted papilloma (IP) has a reported incidence of 0.74 per

100,000/year. The most common site is the lateral nasal wall
[14], while 1–16% of IPs have a frontal sinus origin
(Fig. 21.1). The three main characteristics of IP are its locally
aggressive nature, high recurrence in case of incomplete
resection, and potential to transform or harbor a squamous
cell carcinoma. Squamous cell carcinoma (SCC) can be
found in 9.1% of patients with IP. In the case of frontal sinus
IP, a 22.4% overall recurrence rate was found, with a higher
prevalence of bilateral disease (16%). Also, SCC was found
in 4.1% of IP at this specific site [15]. Krouse staging system
has been used to classify this tumor [16]. CT findings are Fig. 21.1  Endoscopic aspect of an inverted papilloma of the right fron-
unspecific, and most frequently include an isodense unilat- tal sinus with extension to the right nasal fossa

a b

Fig. 21.2  CT scan of an inverted papilloma of the left frontal sinus. (a) Sagittal view showing the tumor in the frontal sinus and recess.
(b) Coronal view of the left frontal sinus, the classic focal hyperostosis can be seen (white arrow)
21  Frontal Sinus Tumours 227

21.3 Malignant Tumors of the Frontal [19]. Overall prognosis is poor, with a 5-year survival rate of
Sinus 50–60% [20], probably because of vague initial symptoms
and delayed diagnosis.
21.3.1 Squamous Cell Carcinoma Therapy for frontal sinus malignancy most often involves
craniofacial resection, as this has been shown to most effec-
·Squamous cell carcinoma (SCC) is the most common sino- tively improve survival rates and local control. Regarding the
nasal malignant tumor, accounting for approximately 41% of efficacy of endoscopic approaches to the frontal sinus in the
frontal malignancies. Wood dust, nickel, formaldehyde, and surgical treatment of malignant disease, the data is still miss-
the presence of an inverted papilloma have been reported as ing. In the rare case of tumor confined to the frontal sinus
risk factors for sinonasal SCC. The tumor usually occurs in with no involvement of the bony walls and located on the
the nasal cavity, followed by the maxillary sinus, and the medial part of the frontal sinus or in the nasofrontal drainage
frontal sinus is less frequently affected (Figs. 21.3 and 21.4) pathway, an endoscopic approach can achieve safe oncologi-
cal results. When the tumor involves the bone or extends to
the skin, the best oncological approach is craniofacial resec-
tion or combined craniofacial and endoscopic resection. In
those cases where the tumor is located unilaterally a blepha-
roplasty incision and posterior osteoplastic frontal bone flap
may be used. If the bone is involved, the defect can be recon-
structed with titanium plates.
Regarding postoperative care we must differentiate
between two situations: (a) when we preserve the frontal
drainage pathway and (b) when we perform a frontal sinus
obliteration. In the event that we can preserve the frontal
sinus pathway, the postoperative debridement in the clinic is
of utmost importance; in our experience, we perform the first
debridement 1  week after surgery, and in case we observe
low inflammatory debris, we continue every 2  weeks until
the mucosa heels. If the patient needs postoperative radio-
therapy, we must visit the patient at least every 3 weeks dur-
ing the radiotherapy and then every month for the first year
in order to avoid obliteration of the frontal drainage pathway.
Fig. 21.3  Lateral view of a patient with a primary SCC of the left Finally, if we perform a frontal obliteration, endoscopic
frontal sinus. Swelling of the central frontal region can be noticed ­follow-­up and debridement are less necessary and can be tai-
clearly lored to each patient.

a b

Fig. 21.4  CT scan of the same patient. (a) Axial view showing erosion of the anterior table of the left and right frontal sinus. (b) Coronal view,
extension to the left orbit can be observed
228 C. Langdon and C. Arancibia

21.3.2 Adenocarcinoma drome in the form of SIADH or calcitonin secretion can be

present [36]. While SNUC is usually EBV virus positive,
Adenocarcinoma is the second or third most common malig- SNEC is usually EBV virus negative. Treatment is multi-
nancy in the sinonasal cavities and the fourth most common modal and depends on the degree of tumor differentiation.
in the frontal sinus [21]. As for other sinonasal malignancies,
clinical presentation is nonspecific. The reported 5-year
disease-­specific survival varies (15.4–66.7%) depending on 21.3.6 Sinonasal Sarcomas
the study. Treatment includes surgery and radiotherapy [21].
Sinonasal sarcomas are rare and comprise only 7% of all
head and neck sarcomas [37]. As other sinonasal malignan-
21.3.3 Sinonasal Undifferentiated Carcinoma cies, they present with obstructive symptoms and/or nasal
discharge. Rhabdomyosarcoma is the most common histo-
·Sinonasal undifferentiated carcinoma (SNUC) is rare and logical type, though it is extremely rare in the frontal sinus.
highly aggressive. Males are more frequently affected and Although treatment is frequently multimodal, there is no
the initial symptoms are vague, the most common being clear protocol. Rhabdomyosarcoma has the worst 5-year sur-
nasal obstruction, epistaxis, visual disturbances, and head- vival (44%) of all sinonasal sarcomas [38].
aches [22]. Most patients are diagnosed in advanced stages,
with orbital or skull base involvement. Distant neck, lung,
and bone metastases have also been reported. Treatment is 21.3.7 Mature B-Cell Non-Hodgkin Lymphoma
usually multimodal, and the tendency to metastasis and
recurrence, explains a poor prognosis with a 5-year survival ·Mature B-cell non-Hodgkin lymphoma (NHL) is a group of
rate of 34.9% [23]. lymphomas that comprise 10% of all sinonasal neoplasms and
represents the second most common sinonasal malignancy
after SCC. They are usually found on the maxillary sinus and
21.3.4 Esthesioneuroblastoma nasal cavity [39], but can also have a frontal sinus origin.
Local symptoms are nonspecific, but other symptoms like
·Esthesioneuroblastoma (ENB), also known as olfactory weight loss and fever may suggest NHL. The 5-year disease-
neuroblastoma, is a rare tumor arising from the olfactory specific survival rate is 63.5–68.0%. Surgery has no role, and
neuroepithelium that accounts for 3–6% of sinonasal malig- treatment includes radiotherapy and chemotherapy [40].
nancies. Histology and immunologic analysis are crucial to
avoid misdiagnosis, which has been reported to be frequent
[24]. Imaging shows a typical dumbbell-shaped mass across 21.3.8 Adenoid Cystic Carcinoma
the cribriform plate, also peritumoral cysts in the tumor–
brain interface is characteristic of ENB [25]. Symptoms are Adenoid cystic carcinoma (ACC) is an uncommon epithelial
nonspecific, and patients present with metastatic disease in malignancy of the upper aerodigestive tract characterized by
around 20–48% of cases. Modified Kadish classification [26, slow growth, recurrence, and perineural invasion. Sinonasal
27] is the most used for staging, and Hyams [28] grading is ACC is even more rare, and the frontal sinus is the least
usually used for histologic grade. Treatment includes surgi- affected of all paranasal cavities [41]. Surgery followed by
cal resection along with radiation therapy and the possibility radiotherapy provides the best overall survival. Endoscopic
of chemotherapy [29–31]. Also, long-term follow-up is surgery is preferred, unless preoperative imaging shows
important, because decade-delayed recurrences have been infiltration of surrounding structures, or free margins cannot
described [32–34]. be obtained [42].

21.3.5 Sinonasal Neuroendocrine Carcinoma 21.3.9 Other Malignant Tumors

·Sinonasal neuroendocrine carcinoma (SNEC) is an Other frontal sinus malignancies are extremely rare and
extremely rare tumor with less than 100 reported cases [35]. include melanoma, fibromatous neoplasms, mature T-cell
Average age of presentation is 56 years, with no specific sex non-Hodgkin’s lymphoma, transitional cell carcinoma, myo-
distribution. Symptoms are non-specific and similar to any matous neoplasms, osseous and chondromatous neoplasms,
other sinus tumor, though in rare cases paraneoplastic syn- and Hodgkin lymphoma [21].
21  Frontal Sinus Tumours 229

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and survival patterns of sinonasal undifferentiated carcinoma in the
United States. J Neurol Surg B Skull Base. 2015;76(2):94–100.
1. Broniatowski M. Osteomas of the frontal sinus. Ear Nose Throat J.
24. Cohen ZR, Marmor E, Fuller GN, et al. Misdiagnosis of olfactory
1984;63(6):267–71.
neuroblastoma. Neurosurg Focus. 2002;12(5):e3.
2. Atallah N, Jay M.  Osteomas of the paranasal sinus. J Laryngol
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 Transorbital Approach to the Frontal
Sinus 22
Giacomo Sollini, Matteo Zoli, Stefano Ratti, Lucia Manzoli,
Diego Mazzatenta, and Ernesto Pasquini

22.1 Introduction approach can be used to access the frontal compartment situ-
ated lateral to the midpoint of the orbit combining the advan-
The transorbital approach to the frontal sinus represents the tages of extended open transcranial procedures with those of
results of multidisciplinary collaboration in the management the transnasal endoscopic approach coplanar [3–6].
of the sino-orbito-cranial interface. The advancements, based Also, an advantage of transorbital approaches is that it
upon improved scientific knowledge and understanding of permits a “4 hands technique” allowing two surgeons to
new surgical anatomy, has taken us to a new different per- work concurrently as the spatial distribution of the portals
spective considering the orbit not only as a target but also as minimizes collision/collusion of the surgeon’s hands [7].
a virtual corridor for access to different areas.
In 2010 and 2011, Moe et al. [1, 2] introduced the concept
of transorbital endoscopic surgery which represents a variety 22.2 Indications
of transorbital endoscopic approaches (TOEAs) devised to
target skull base diseases through a single corridor or a com- For diseases of the lateral compartment of the frontal sinus
bination of four major transorbital corridors (superior, infe- that cannot be properly managed by an exclusive transnasal
rior, medial, and lateral). Since its outset, the TOEA has endoscopic approach, TOEA represents a less-invasive alter-
gained interest as a minimally invasive adjunct to the surgi- native route to the frontal craniotomy. In our experience, the
cal armamentarium for the management of several skull following pathological conditions may be effectively
base/sinonasal diseases bypassing some limitations pre- approached through such route:
sented in endonasal and transcranial approaches [2–8].
Notably, TOEA through the superior eyelid crease corridor • Inflammatory disease: sinonasal, orbital, and intracranial
has been shown to provide a coplanar direct pathway to the mucocele; frontal sinusitis associated with unfavorable
frontal sinus, making it a valuable tool to consider when deal- anatomical variations (for transnasal procedure alone).
ing with diseases arising in this location. In selected cases, this • Noninflammatory disease: frontal sinus CSF leak, benign
tumors (osteomas, meningiomas and others), fibrous
Supplementary Information The online version contains supplementary dysplasia.
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_22].
The authors’ experience comprises only combined trans-
G. Sollini (*) · E. Pasquini nasal–transorbital procedures.
Unit of Otorhinolaryngology - Head & Neck Surgery, Bellaria
Hospital, Bologna, Italy
e-mail: [email protected]; [email protected]
S. Ratti · L. Manzoli 22.3 Schematic Description. Anatomical
Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Istituto Landmarks
delle Scienze Neurologiche di Bologna, Bologna, Italy
e-mail: [email protected]; [email protected] For the transorbital approach to the frontal sinus, the most
M. Zoli · D. Mazzatenta relevant anatomical structures are represented by the eyelid
Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Istituto and by the orbital roof.
delle Scienze Neurologiche di Bologna, Bologna, Italy
The skin of the superior eyelid is very thin and its thickest
Department of Bio-Medical and Neuro-Motor Sciences, University part, just below the eyebrow, measures almost 1.2 mm. Just
of Bologna, Bologna, Italy
e-mail: [email protected]; [email protected] below this layer, the fibers of the orbicular oculi muscle

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 231
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_22
232 G. Sollini et al.

a b

Fig. 22.1  Superior eyelid approach. Skin incision is made in a crease of the upper eyelid skin (skin has been removed in this dissection) and the
orbicularis oculi muscle (OOM) is identified (red dashed line) B Superior tarsus (Ta) and levator palpebrae muscle (LPM) are identified

(OOM) divide in a pretarsal (inferior) and preseptal (supe- 22.4 Preoperative Tips (Individual Risk
rior) part. The orbital septum (OS) is usually located deep to Factors, Radiology, Instrumentation)
the preseptal part of the OOM. It originates from the orbital
rim at the arcus marginalis and inserts onto the levator palpe- 22.4.1 Radiology
brae muscle (LPM) aponeurosis (Fig. 22.1). The OS contin-
ues superiorly with the periosteum of the orbital rim that Preoperative computer tomography (CT) should be per-
represents the anterior border of the orbital roof. formed before every endoscopic transorbital procedure.
The orbital roof is formed by two skull bones: the lesser For noninflammatory diseases or mucoceles, magnetic
wing of the sphenoid bone, which constitutes a lesser deep resonance imaging (MRI), with or w/o gadolinium, is strongly
and medial portion and the orbital plate of the frontal bone, recommended for its high contrast resolution combined with
which represents the main structure of the orbital roof. This multiplanar capability that enables discrimination between
latter part also constitutes the floor of the frontal sinus. One lesion and retained secretion and a better definition of the
of the more relevant bony structures in the frontal bone is the relationships with adjacent structures (especially in case of
supraorbital notch and foramen (SON/F), where the supraor- intracranial or intraorbital extension). In the case of suspected
bital neurovascular complex runs, formed by the supraorbital meningoencephalocele/meningocele, we specifically require
nerve (CN V1) and arterial and venous vessels. fluid-attenuated inversion recovery (FLAIR) sequence: this
Although it has been reported that the SON/F would be special sequence removes the signal of the cerebrospinal fluid
located at the junction of the medial third and lateral two-­ (CSF) ensuring the differentiation between inflammatory tis-
thirds of the supraorbital margin, recent studies have sue/meningocele and areas containing CSF.
reported a high variability of the course of the supraorbital In our center, a magnetic image-guided navigation system is
nerve at its passage at the superior orbital rim. Facial mid- routinely adopted for transorbital approach and transorbital–
line, the temporal crest of the frontal bone, and frontozygo- transnasal combined approach [8]. This helps the surgeon in
matic suture are described as relevant potential landmarks identifying the correct transorbital access point to the frontal
for intraoperative localization of the SON/F [9, 10] sinus and in getting oriented, especially when managing
(Fig. 22.2). extended osseous/fibro-osseous lesions inside the frontal sinus.
22  Transorbital Approach to the Frontal Sinus 233

a b

Fig. 22.2 (a) The orbital rim (OR) is detached from the periorbita (Pe). (b) Identification of the supraorbital neurovascular pedicle (SOP) running
from the orbit through the supra orbital foramen (SOF) to the frontal area

22.4.2 Instrumentation

We recommend the following instrumentation in the surgical

set: 0°, 30°, and eventually 70° 2D or 3D endoscopes; mal-
leable retractor; magnetic navigation system; bipolar cau-
tery; periosteal elevator or Freer elevator; 3–4  mm round
drill; Kerrison rongeur.

22.5 Pearls and Potential Pitfalls

Preoperative radiological evaluation of the frontal sinus

pneumatization is mandatory, indeed only well pneumatized
frontal sinus with an adequate anteroposterior extension
should be selected for this approach.
A “multiportal approach” combining the TOEA with the
standard endoscopic transnasal approach to the frontal sinus,
is always preferable for better control of the natural sinus
drainage pathway (Fig. 22.3).

Fig. 22.3  Skull base reconstruction (transnasal view) after the removal
22.6 Surgical Procedure of a frontoethmoidal osteoma. The two surgeons are working simulta-
neously, once from the frontal sinusotomy (Draf III), once from the
transorbital opening
As in standard transnasal endoscopic procedure, the patient
is placed supine, with the thorax slightly elevated at 20°
and the head moderately rotated toward the first surgeon. or 3D camera. The navigation system was implemented in
Surgery is performed under general anesthesia with orotra- all cases and set before starting the surgery. The surgical
cheal intubation, and it can be conducted using 0° and field has to include the entire facial area including the
angled (30° or 45°) endoscopes with a high-definition 2D forehead.
234 G. Sollini et al.

When needed, the transorbital approach may be com-

bined with a transnasal one. In these cases, it is preferable to
perform first the Draf IIb or Draf III frontal sinusotomy, and
then to proceed with the already described transorbital route.
The incision is made in a crease of the upper eyelid skin
as done in an upper blepharoplasty (6–8 mm from the ciliary
margin) and can be tailored according to the path-to-target
analysis. At this point, the orbicularis muscle should be iden-
tified. Dissection of the muscle should be performed with
blunt instruments, taking care to follow a preseptal plane,
harvesting a suborbicularis flap. Following superiorly the
orbital septum up the orbital rim, the elevator palpebrae mus-
cle can be spared and entering inside the orbit with conse-
quent prolapse of orbital fat into the surgical corridor may be
avoided. The supraorbital and the supratrochlear neurovas-
cular pedicles should be identified and preserved (Figs. 22.4
and 22.5).
After the identification of the orbital rim, the periosteum
is incised and the periorbita dissected from the orbital roof.
The dissection proceeds posteriorly under endoscopic visu-
Fig. 22.4  An incision similar to that of an upper blepharoplasty is
alization while the orbit is gently moved inferiorly with a made in a skin crease of the upper eyelid
malleable retractor (Fig. 22.6).
At this point, surgical navigation is used to confirm the
correct position of the frontal sinus and the pathologic target,
allowing the surgeon to perform the transorbital sinusotomy
safely.
The osteotomy in the orbital roof can be performed using
a 3 mm diamond burr and Kerrison’s rongeur and should be
tailored as necessary to provide a surgical corridor enabling
endoscopic visualization with a 4  mm endoscope (0° or
angled scopes, according to each case peculiarities) and
simultaneous surgical manipulation if needed (Fig. 22.7).
After the surgical resection, in case of a large defect or in
case of periorbital damage with herniation of fat, orbitotomy
should be reconstructed with both cosmetic and functional
Fig. 22.5  Suborbicular flap with blunt instruments, taking care to fol-
aims. We prefer a single nonporous sheet of collagen matrix low a preseptal plane, identifying and preserving the supraorbital and
(porcine-derived) normally utilized in skull base reconstruc- supratrochlear neurovascular pedicles

a b

Fig. 22.6 (a, b) An incision is made in the periosteum after the identification of the orbital rim and the periorbita is dissected from the orbital roof
22  Transorbital Approach to the Frontal Sinus 235

Periosteum of the orbital rim should be dissected from

lateral to medial, taking care not to damage the supraorbital
pedicle that should be encountered at the junction of the
medial one third and lateral two-thirds of the supraorbital
margin.
After the periorbital dissection, the orbital content can be
protected with a Silastic sheet. This can also reduce the fat
protrusion into the surgical corridor in case of accidental
opening of the periorbita.
We suggest checking the location of the frontal sinus with
the navigation system before proceeding with the osteotomy.
In our experience, it is advantageous to approach the frontal
Fig. 22.7  Transorbital frontal access with 4  mm round drill in left sinus as laterally as possible to avoid any potential alteration
frontoethmoidal osteoma
of the physiologic frontal drainage.
Frontal sinus obliteration with abdominal fat and com-
plete mucosal removal should be considered in case of
extended defects, poor quality exposed dura, or CSF leak not
manageable with other reconstructive techniques [3].

22.7 Postoperative Tips

Corticosteroid therapy is routinely administered for the fol-

lowing 7–10 days to avoid postoperative palpebral edema.
We recommend that patients do not blow their nose for
the next 15 days after surgery to avoid orbital emphysema.
Postoperative diplopia may occur for several weeks after
surgery depending on the location of pathology, degree of
retraction during surgery, and preoperative globe displace-
ment by the pathology; either way, permanent diplopia due
to surgical intervention has not been reported in the litera-
ture, yet. Transient diplopia does not usually request any
management but in case of long-term alteration ophthalmo-
logical evaluation is suggested.
Temporary forehead paresthesia, typically lasting
Fig. 22.8  A sheet of Biodesign® repair graft is used to reconstruct the 3–6 months, is an expected outcome during superior transor-
skull base defect and orbitotomy
bital approaches due to dissection and retraction of the
supraorbital neurovascular bundle [4].
tion but also application of synthetic materials (polydioxa-
none) or fascia lata is described (Fig. 22.8) [4].
The orbicularis muscle and the palpebrae skin are closed References
in two layers with adsorbable suture.
The skin incision should be tailored to the target of the 1. Moe KS, Bergeron CM, Ellenbogen RG. Transorbital neuroendo-
scopic surgery. Neurosurgery. 2010;67:ons16–28.
surgery. In the approach phase, OOM can be identified, con- 2. Moe KS, Kim LJ, Bergeron CM. Transorbital endoscopic repair of
sidering the direction of the fibers: those of OOM fibers run cerebrospinal fluid leaks. Laryngoscope. 2011;121:13–30.
horizontally while LPM fibers are vertical. The dissection 3. Noiphithak R, Yanez-Siller JC, Nimmannitya P, Rukskul
should be conducted very carefully at this level due to the P.  Transorbital endoscopic approach for repair of frontal
sinus cerebrospinal fluid leaks: case-series. Laryngoscope.
reduced thickness of the layers. In case of LPM aponeurosis 2020;131(8):1753–7.
or fibers injury, readsorbable sutures are useful to reconstruct 4. Miller C, Berens A, Patel SA, Humphreys IM, Moe KS. Transorbital
these structures to avoid ptosis. approach for improved access in the management of paranasal sinus
Once the orbital rim is identified, the musculocutaneous mucoceles. J Neurol Surg B Skull Base. 2019;80(6):593–8.
5. Lim JH, Sardesai MG, Ferreira M Jr, Moe KS. Transorbital neuro-
flaps can be fixed with stitches. endoscopic management of sinogenic complications involving the
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frontal sinus, orbit, and anterior cranial fossa. J Neurol Surg B Skull 8. Zoli M, Sollini G, Milanese L, La Corte E, Rustici A, Guaraldi
Base. 2012;73(6):394–400. F, Asioli S, Cirillo L, Pasquini E, Mazzatenta D.  Endoscopic
6. Hicks KL, Moe KS, Humphreys IM.  Bilateral transorbital and approaches to orbital lesions: case series and systematic literature
transnasal endoscopic resection of a frontal sinus osteoblastoma review. J Neurosurg. 2020;134(2):608–20.
and orbital mucocele: a case report and review of the literature. 9. Haładaj R, Polguj M, Topol M. Anatomical variations of the supraor-
Ann Otol Rhinol Laryngol. 2018;127(11):864–9. bital and supratrochlear nerves: their intraorbital course and relation
7. Dallan I, Castelnuovo P, Locatelli D, et al. Multiportal combined to the supraorbital margin. Med Sci Monit. 2019;13(25):5201–10.
transorbital transnasal endoscopic approach for the management 10. Nanayakkara D, Manawaratne R, Sampath H, Vadysinghe A, Peiris
of selected skull base lesions: preliminary experience. World R.  Supraorbital nerve exits: positional variations and localization
Neurosurg. 2015;84:97–107. relative to surgical landmarks. Anat Cell Biol. 2018;51(1):19–24.
 Revision Surgery of the Frontal Sinus
23
Javier Ospina and Arif Janjua

23.1 Introduction and extended approaches, which the reader can find in other
chapters of this book.
Rhinologists and sino-nasal surgeons have long considered
the frontal sinus to be the most difficult sinus to aerate and
ventilate - and most importantly most challenging to keep 23.2 Indications
open, after surgery as well is the most challenging. These
difficulties are secondary to its unique anatomic location Revision frontal sinus surgery is indicated when the frontal
(that frequently necessitates the use of angled endoscopes sinus drainage pathway remains obstructed after a surgical
and angled instrumentation), proximity to critical structures procedure, with either persistent patient symptomatology
(e.g., brain and orbits), potentially narrow outflow tract, and (e.g., frontal headaches) or obstruction that puts the patient
heterogeneous anatomy [1, 2]. at risk for complications such as a persistent chronic infec-
As has been explained extensively throughout this book, tion of the frontal sinus and/or the formation of a mucocele.
the key to obtaining long-term frontal sinus patency is creat- Careful evaluation of the reasons that led the previous
ing a wide ventilation/drainage pathway for the frontal sinus, operation to fail is of upmost importance. Ongoing obstruc-
while at the same time avoiding undesirable scarring that tion could be the result of scar tissue, bone hyperostosis, or
narrows or obliterates the frontal sinus outflow tract after severe inflammatory disease. Several factors could be found
surgery. Prevention of postoperative stenosis results from a in combination in the same patient, and the clinician should
combination of in-depth understanding of the individual’s determine the most appropriate surgical and medical strate-
frontal sinus anatomy and minimizing mucosal damage to gies for each case.
the walls of the frontal recess during the dissection. This is,
however, frequently very difficult to achieve, especially in
revision cases. 23.3 Schematic Description (Anatomy:
This chapter aims to summarize the preoperative evalua- Expected Result)
tion, surgical nuances, and key recommendations that a rhi-
nologist/sinus surgeon should take into consideration in
order to have a successful outcome in revision frontal sinus
surgery. Here, we describe the endoscopic endonasal 23.4 Preoperative Tips (Individual Risk
approach for revision cases, excluding open, trans-orbital, Factors, Radiology, Instrumentation)

Supplementary Information The online version contains supplementary 23.4.1 Individual Risk Factors
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_23].
If the surgeon has doubts whether the frontal sinus could be
adequately opened using an endoscopic approach, patient’s
J. Ospina (*)
Division of Rhinology and Skull Base Surgery, Department of consent should be obtained before surgery for other adjunct
Otolaryngology—Head and Neck Surgery, Instituto Nacional de surgical procedures such as the use of a frontal sinus tre-
Cancerología, Fundación Santa Fe de Bogotá, Bogotá, Colombia phine, trans-orbital approach, or open approaches, described
A. Janjua in other chapters of this book.
Rhinology, Endoscopic Sinus and Skull Base Surgery, Division of Individuals with extensive polypoid disease with inflam-
Otolaryngology—Head and Neck Surgery, University of British
mation refractory to medical treatment and/or significant
Columbia, Vancouver, BC, Canada

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 237
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_23
238 J. Ospina and A. Janjua

bony neo-osteogenesis should be identified preoperatively, Commonly used frontal sinus instruments
as these features will most certainly have an impact in the –– 30° and 70° endoscopes (4 mm diameter, reverse-posted:
healing process after revision surgery and have a significant fiber light cable on the same side as the angulation of the
impact on the best surgical strategy and peri-operative medi- scope).
cal approach after revision frontal sinus surgery. –– Kerrison rongeur size, up-biting, 1 and 2 mm.
–– Kuhn frontal sinus seeker curved 45° and 90°, and poten-
tially several other different permutations of frontal sinus
23.4.2 Radiology seekers (with a forward, back, right, and left right-angle
hooks at the end).
Meticulous preoperative evaluation of the patient’s CT scan –– Angled shaver blades. The authors specifically frequently
is of upmost importance in revision cases. The following are utilize a 90°-angled shaver blade (i.e., RAD90); this is
key areas that the surgeon should pay specific attention to: particularly useful if the surgeon anticipates severe polyp-
oid disease within the frontal sinus or complex cells that
–– The A–P diameter of the frontal sinus recess (best visual- exist high up inside the frontal sinus.
ized in the sagittal cuts). –– Giraffe forceps 55°, double-spoon, 2  mm diameter, and
–– Projection, prominence, and thickness of the nasofrontal 13 cm working length. Both “front to back” and “side to
beak. side” configurations.
–– Presence of complex frontal sinus cells not adequately –– Frontal sinus through-cutting instruments, 65°, width of
exenterated (e.g., supra-agger and/or supra-bullar cells). cut 1.5 mm, 13 cm working length (e.g., Castelnuovo or
–– Identify the position of the middle turbinate and its supe- Kuhn Rhinoforce). “Front to back,” “opening to the left,”
rior attachment. It is common in revision cases to find that and “opening to the right” configurations.
the stump of a partially resected middle turbinate is later- –– Hosemann frontal sinus/recess punch, 70° upturned. Head
alized and fused to the anterior lateral nasal wall, obliter- diameter 2.5 mm.
ating the frontal recess (see Fig. 23.1). –– Frontal sinus rongeur (aka “cobra”), 70° upturned, for-
–– Identify any dehiscence of the lamina papyracea ward cutting, jaws 2.5 × 2.4 mm. working length 13 cm.
(Fig. 23.2). –– If an extended approach is anticipated or severe bone
–– Identify any dehiscence of the posterior table of the fron- hyperostosis is obliterating the recess, the surgeon should
tal sinus (the anterior skull base). have access to diamond and/or cutting drills (see Chap.
–– Identify if there is hyperostotic bone that narrows or oblit- 14, Draf III).
erates the frontal recess.
–– Identify the severity of inflammatory changes within the
frontal sinus. 23.5 Pearls and Potential Pitfalls

The surgeon should anticipate if the patient requires an

23.4.3 Instrumentation extended frontal sinus approach in order to achieve a favor-
able outcome in revision cases. In the authors’ experience, in
Frontal sinus surgery is the nasal surgical procedure that per- the majority of cases, revision frontal sinus aeration requires
haps necessitates the most specialized instruments in order at least a Draf IIA approach (described in Chap. 12 of this
to achieve atraumatic dissection technique. This is even more book), in which all the frontal recess ethmoid partitions and
evident in revision cases. Therefore, we consider that the complex frontal cell walls are completely removed.
revision frontal sinus surgeons need to have several different The surgeon should carefully evaluate if a patient who
instrument permutations in their armamentarium to obtain has previously failed a Draf IIA frontal sinusotomy may
sufficient access to all the corners of the frontal recess and require a wider surgical approach to the frontal sinus.
sinus. Certainly, not all revision cases require an “extended”
The following is the list of instruments that the authors approach to the frontal recess, and most patients require
use more commonly in revision frontal surgery. However, revision frontal surgery simply because of incomplete dis-
the surgeons should use their experience to determine the section of the ethmoid and frontal recess septations or post-
instruments that they are most comfortable with. operative narrowing/closure.
23  Revision Surgery of the Frontal Sinus 239

a b

c d

Fig. 23.1 (a) 0° endoscopic view of the right nasal cavity of a patient scope, showing the limits of the frontal recess dissection. (d)
who had previous surgery for CRSwNP, showing a thick scar band/ Postoperative endoscopic view of patent frontal sinusotomy 6 months
synechiae (S) between the lateral nasal wall (LNW) and the middle after revision frontal surgery. FB frontonasal beak, MTs middle turbi-
turbinate (MT). (b, c) Endoscopic intraoperative view using a 70° endo- nate stump, AEA anterior ethmoidal artery, Lamina lamina papyracea

Lateral: The medial wall of the orbit is another constant

23.6 Surgical Procedure: Key Steps landmark that should be found on the lateral aspect of the
frontal recess. The surgeon should be aware of its integrity
23.6.1 Meticulous Endoscopic Examination preoperatively. When the bony wall is dehiscent, the muco-
and Identification of Remaining salized periorbita can be used as the lateral landmark.
Anatomical Landmarks Anterior: The posterior surface of the frontonasal beak is
the anterior landmark that the surgeon can use to find the
Surgical landmarks are not always visible at the beginning of frontal sinus. In the authors’ experience, the posterior sur-
the operation in revision cases. The surgeon should aim to face of the beak is best identified with a heavily angled scope
find them during the dissection. (e.g., 70°). This can be done by removing the superior wall
Medial: Usually, the anterior vertical lamella of the mid- of the agger nasi cell until it reaches its anterior attachment.
dle turbinate or the stump of the previously resected MT at Posterior: The skull base/posterior table of the frontal sinus.
its attachment to the skull base can be found during surgery. The skull base should be identified and broadly exposed in the
This should be considered the medial landmark of the frontal posterior ethmoid. Subsequently, an angled endoscope can be
sinus drainage pathway. used to identify the “inflection point” of the cranial base at
240 J. Ospina and A. Janjua

a b c

Fig. 23.2  Dehiscence of the right lamina papyracea in a previously operated patient with CRSwNP. (a) Coronal cut. (b) Axial cut. (c) Intraoperative
endoscopic view of periorbital prolapse into the ethmoid cavity

which the fovea ethmoidalis turns upward to create the poste-

rior table of the frontal sinus. The surgeon should always try to
identify and avoid injury of the anterior ethmoidal artery that
lies within the bony cranial base, or hanging slightly below it,
at the approximate position of this “inflection point.”
By identifying these four anatomical boundaries of the
widest possible frontal sinus outflow tract, the revision sur-
geon can establish the “outer limits” of the frontal sinus dis-
section. Removal of all bony septations, scar tissue, and/or
hyperostotic bone within these four outer walls would result
in the largest possible type IIA frontal recess dissection.

23.6.2 Wide Exposure of the Middle Turbinate

Axilla

Aggressive dissection of the area superiorly between the mid-

dle turbinate and the ascending frontal process of the maxilla Fig. 23.3  Postoperative endoscopic view of a patient who underwent
revision FESS with revision frontal sinusotomy. Arrows indicate the
is very useful to obtain adequate exposure to the frontal recess broad exposure obtained in the middle turbinate axilla area. Eth eth-
(see Fig. 23.3). The authors routinely use Kerrison rongeurs moid cavity, MT middle turbinate, Max maxillary sinus
to obtain wide exposure in this area. Obstructing scar tissue is
frequently found here in revision cases. The surgeon must
have a plan to maintain the patency of this area postopera- Rigorous exenteration of all ethmoid septations in the frontal
tively (e.g., axillary flap, middle meatal spacer use). sinus drainage pathway is essential to achieve wide exposure
and clearly identify the limits of dissection previously
described. The surgeon should exenterate the ethmoid cells
23.6.3 Complete Ethmoidectomy and identify the four “outer limits” described above, before
addressing the frontal sinus itself. Further, wide exposure
A common cause of failure in previous frontal sinus dissec- inferiorly in the recess facilitates better overall frontal sinus
tions is incomplete removal of all ethmoid partitions. instrumentation.
23  Revision Surgery of the Frontal Sinus 241

23.6.4 Sharp Frontal Recess Dissection of the other three walls. The surgeon may additionally think
about stenting or mucosal grafting techniques.
Through-cutting instruments are important to be used in this
area. The surgeon should prevent, as much as possible, unde-
sired removal of mucosa from the outer walls of the frontal 23.6.6 Maintain Postoperative Patency
recess—because this inevitably leads to postoperative scar-
ring and obstruction. If denuded bone exposure is certain, the This is indeed the most difficult task to achieve in revision
surgeon should contemplate and balance the benefits of gain- cases. If the surgeon is able to achieve a wide frontal sinus
ing more space for ventilation and medication delivery ver- opening without a denuded bone on the “outer walls” of the
sus denuding more bone. If the surgeon elects to create a frontal recess, very often it is not necessary to do anything
wider opening and as a result exposes more raw bone, the else to achieve adequate postoperative patency. However,
surgeon may consider a wider approach (i.e., Draf IIb or when the recess is narrow or there is significant denuded
Draf III) or decide to use a stent in the frontal recess or a bone, several different techniques have been described which
combination of both (Figs. 23.4 and 23.5). could help to maintain satisfactory patency of the frontal
sinus.

23.6.5 Possible (Partial) Resection

of Frontonasal Beak 23.6.7 Stenting Techniques

This is often necessary when the frontal beak is prominent A limited number of studies suggest that frontal sinus stent-
and substantially reduces the frontal recess A–P diameter. In ing techniques are effective to maintain postoperative
this setting, the surgeon may elect to remove that bone anteri- patency of the frontal sinus. However, the exact indication
orly. This task could be performed with the use of frontal and optimal duration of stenting are unknown [3, 4].
sinus rongeur, Hosemann frontal sinus punch, or curved drill. Stents are recommended when a surgeon encounters
The surgeon should expect that the anterior wall would be extensive polyp disease, a floppy or lateralized middle turbi-
inevitably denuded, and therefore, the surgeon should remove nate, intraoperative diameter of the frontal sinus ostium of
the maximal amount of bone anteriorly to gain the largest less than 5 mm, or the dissection results in circumferential
increase of frontal recess diameter and avoid stripping mucosa bone exposure [3, 5].

a b

Fig. 23.4  Preoperative CT scan of a patient who underwent revision complex partitions within the frontal recess. (c) Endoscopic postopera-
frontal sinusotomy. (a) Coronal cut showing significant lateralization of tive view of the same patient 1  year after revision bilateral Draf IIb
the right middle turbinate. (b) Sagittal cut. Arrow indicates persistent frontal sinusotomy. (c) Right side. (d) Left side
242 J. Ospina and A. Janjua

c d

Fig. 23.4 (continued)

a c

Fig. 23.5  Preoperative CT scan of a patient who underwent revision erative view of the same patient 1 year after left revision Draf IIb frontal
frontal sinusotomy. (a) Coronal cut. (b) Sagittal cut. Arrow indicates sinusotomy. SB skull base, Lamina lamina papyracea
anterior ethmoidal and undissected frontal cells. (c) Endoscopic postop-
23  Revision Surgery of the Frontal Sinus 243

a b

c d

Fig. 23.6 (a, b) Intraoperative endoscopic view of a modified, rectan- frontal sinus immediately before its removal. (d) Same as (c) just after
gular, 0.51 mm silastic sheet placed into the left frontal sinus after revi- the removal of the stent. Mild polypoid stent reaction within the sinus is
sion frontal surgery. The stent is easily placed with a giraffe, 55°, noted. This is typical and settles shortly after removal. The “stretched”
side-to-side grasper. (c) Endoscopic postoperative view of the same appearance of the frontal sinus opening should also be noted
patient 12 weeks after surgery, showing the stent in place and the patent

Options include a wide array of stents that are both rigid cially available Rains frontal sinus stents made of silicone
and pliable, made from absorbable and nonabsorbable mate- (Fig. 23.7)—although these do not provide the same advan-
rials. Very few reports have described complications associ- tage of constant radial pressure and as such are not favorable
ated with frontal sinus stenting techniques [6]. to the authors.
The authors’ preference is to customize a piece of silastic Of note, silastic stents are inexpensive, inert, and easy to
(medical grade silicone) sheeting 0.51  mm in thickness customize to the shape/size of the frontal sinus outflow
(Fig.  23.6) into a rectangular shape which can unfurl and tract. They are “hollow” and create an avenue to deliver
continue to apply some radial pressure and “stretch” the steroid-­impregnated sinus rinses into an inflamed frontal
frontal recess during healing. The stents are kept in place for sinus. They appear to be very well tolerated, with most
a variable duration based on the amount of prior scar patients unaware of a foreign body sensation at all. The
resected and the amount of exposed/denuded bone within authors also have significant experience in using them for
the frontal recess. If the frontal recess has circumferential longer periods of time (>3  months) in patients who are
bone exposure (360°), the authors leave the stent in place for going to be radiated as a part of adjuvant therapy for sino-
12 weeks. Alternatively, the authors have utilized commer- nasal malignancies.
244 J. Ospina and A. Janjua

a b c

Fig. 23.7  Preoperative CT scan of a patient who underwent revision 8 months after revision surgery and Rains frontal stenting. Note that the
left frontal sinusotomy. (a) Coronal cut. (b) Sagittal cut. (c) Endoscopic outflow tract takes the shape of the Rains stent
postoperative view of the same patient with patent frontal sinus

Fig. 23.8  Endoscopic intraoperative view of a drug-eluting stent (Propel mini) placed into the left frontal sinus recess. MT middle turbinate,
F frontal, Lamina lamina papyracea. Courtesy Dr. Sammi Khalili MD, MSc, FRCSC, Aurora Neuroscience Innovation Institute

23.6.7.1 Steroid-Eluting Stents nasal polyposis in the frontal recess in selected patients.
More recently, drug-eluting stents have been introduced and However, they are costly—approximately 500 times the
have been well studied. Drug-eluting stents have specifically cost of a silastic sheet—and as such not yet widely avail-
been used for patients with refractory frontal disease who able for use [7, 8].
undergo revision frontal surgery. Steroid-eluting stent com-
posed of a polylactide-co-glycolide scaffold impregnated
with 370  mg of mometasone furoate was designed by 23.6.8 Mucosal Graft Transplants and Local
Intersect ENT (Propel, Menlo Park, CA, USA) in 2011. Mucoperiosteal Flaps
Since then, they have been used by many sinus surgeons to
“stent” open the maximally dissected frontal recess while The Draf III approach, also known as Endoscopic Modified
releasing steroids directly to the mucosa over 30 days post-­ Lothrop Procedure (EMLP) or frontal sinus drill-out, is a
surgery [3] (Fig. 23.8). well-established procedure with a high success rate. It is
These slow-resorbing steroid-releasing implants seem described in detail in Chap. 14 of this book. However, sig-
to be a promising option for the treatment of recurrent nificant osteoneogenesis, scarring, and stenosis may occur
23  Revision Surgery of the Frontal Sinus 245

after this extensive drilling in the frontal recess, leading to References

failure in a small proportion of patients [9]. As a conse-
quence, several authors have described the use of mucosal 1. Dassi CS, Demarco FR, Mangussi-Gomes J, Weber R, Balsalobre
L, Stamm AC.  The frontal sinus and frontal recess: anatomical,
grafts to circumvent this. These techniques aim to improve radiological and surgical concepts. Int Arch Otorhinolaryngol.
healing and minimize stenosis by grafting mucosa from the 2020;24(3):364–75. https://doi.org/10.1055/s-­0040-­1713923.
septum (that would normally be resected), from the lateral 2. Baban MIA, Mirza B, Castelnuovo P. Radiological and endoscopic
nasal wall or from the floor of the nose, to cover the drilled/ findings in patients undergoing revision endoscopic sinus surgery.
Surg Radiol Anat. 2020;42(9):1003–12. https://doi.org/10.1007/
exposed bone [10, 11]. Other surgeons have described the s00276-­020-­02427-­5.
use of mucoperiosteal rotation flaps in Draf IIb and III fron- 3. Hauser LJ, Turner JH, Chandra RK. Trends in the use of stents and
tal sinusotomies, demonstrating promising results in terms drug-eluting stents in sinus surgery. Otolaryngol Clin North Am.
of frontal cavity restenosis prevention, with a favorable 2017;50(3):565–71. https://doi.org/10.1016/j.otc.2017.01.007.
4. Shahidi S, Jama GM, Ahmed SK. The use of modified Silastic nasal
­healing process and minimized crusting during the postop- splints as frontal sinus stents: a technical note. J Laryngol Otol.
erative period [12] (see Chap. 28). 2020;134(3):270–1. https://doi.org/10.1017/S0022215120000456.
In the author’s experience, raising these flaps and grafts 5. Orlandi RR, Knight J.  Prolonged stenting of the frontal sinus.
endoscopically is possible and can aid with healing. The Laryngoscope. 2009;119(1):190–2. https://doi.org/10.1002/
lary.20081.
downsides are that they are frequently time-consuming and 6. Khan MA, Alshareef WA, Marglani OA, Herzallah IR.  Outcome
difficult to keep in place postoperatively and commonly the and complications of frontal sinus stenting: a case presentation and
quality of the mucosa being transplanted is poor—and likely literature review. Case Rep Otolaryngol. 2020;2020:1–4. https://
neo-mucosalization may be a better alternative. doi.org/10.1155/2020/8885870.
7. Luong A, Ow RA, Singh A, et al. Safety and effectiveness of a bio-
absorbable steroid-releasing implant for the paranasal sinus ostia:
a randomized clinical trial. JAMA Otolaryngol Head Neck Surg.
23.7 Postoperative Tips 2018;144(1):28–35. https://doi.org/10.1001/jamaoto.2017.1859.
8. Huang Z, Huang Q, Zhou B, Ma J, Wang M, Dong Y. Bioabsorbable
steroid-eluting sinus stents for patients with refractory frontal dis-
Rigorous postoperative care is an integral part of the surgical eases undergoing a revision Draf 3 procedure: a case series. Acta
procedure. The surgeon should utilize an angled endoscope Otolaryngol. 2019;139(7):636–42. https://doi.org/10.1080/000164
(30° or 45°) and angled suctions and/or instrumentation in 89.2019.1592222.
the clinic for endoscopically guided postoperative debride- 9. Shih LC, Patel VS, Choby GW, Nakayama T, Hwang PH. Evolution
of the endoscopic modified Lothrop procedure: a systematic review
ments. The goal of postoperative care is to minimize the pos- and meta-analysis. Laryngoscope. 2018;128(2):317–26. https://doi.
sibility of re-stenosis by removing obstructing granulation org/10.1002/lary.26794.
tissue and decreasing local inflammation. 10. Citardi MJ, Javer AR, Kuhn FA. Revision endoscopic frontal sinus-
When frontal sinus silastic stents are utilized, the authors otomy with mucoperiosteal flap advancement: the frontal sinus
rescue procedure. Otolaryngol Clin North Am. 2001;34(1):123–32.
aim to avoid too early removal as much as possible. It seems https://doi.org/10.1016/S0030-­6665(05)70300-­5.
that it is better to leave the stent in place until the frontal 11. Wang YP, Shen PH, Hsieh LC, Wormald PJ.  Free mucosal
recess is completely re-mucosalized. The authors’ impression grafts and anterior pedicled flaps to prevent ostium restenosis
is that the silastic stents aid in the re-mucosalization process after ­endoscopic modified Lothrop (frontal drillout) procedure:
a randomized, controlled study. Int Forum Allergy Rhinol.
by preventing drying and crusting of exposed bone when 2019;9(11):1387–94. https://doi.org/10.1002/alr.22416.
exposed to inspired air. The authors hypothesize that silastic 12. Khoueir N, Verillaud B, Castelnuovo P, Herman P. Value of dou-
may also lead to the trapping of inflammatory mediators ble mucoperiosteal flaps to prevent restenosis in Draf II b/III: first
beneath the stent and improve the healing/re-­mucosalization clinical report. Clin Otolaryngol. 2018;43(2):746–9. https://doi.
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process, but this effect has not been proven yet.
 Treatment of Frontal Sinus Trauma
and CSF Leaks 24
Sara Zaldívar Saiz-Maza, Alfonso Santamaría-Gadea,
and Franklin Mariño-Sánchez

Table 24.1  Early and late complications of frontal sinus fractures

24.1 Introduction
Early complications (<6 months) Late complications (>6 months)
Acute sinusitis Hypoesthesia
Frontal sinus fractures represent 5–15% of all maxillofa-
Hematoma Contour irregularities
cial fractures [1]. It is the strongest bone in an adult face, Wound infection Osteomyelitis
requiring a significant force between 800 and 2200 pounds CSF leak CFS leak
to result in a fracture [2]. Consequently, these types of frac- Meningitis Meningitis
ture usually result from high-speed injuries, such a motor Mucocele/mucopyocele
vehicle collision, falls, assaults, or sporting-related trauma Brain abscesses
[3]; hence, they are frequently observed in polytraumatized Chronic pain
patients and can lead to important both intracranial and
extracranial complications, including meningitis, encepha-
litis, intracranial abscesses, osteomyelitis, and mucoceles Cerebrospinal fluid (CSF) leak results from any com-
(Table 24.1) [4]. munication between the subarachnoid space and the sino-
Over the years, multiple classifications of frontal sinus nasal cavity. It is a serious and potentially fatal condition,
fractures have been described in the literature [5–9]. Most because of the increased risk of developing meningitis
of them are based on the assessment of the injuries of the (10% per year) [12]. The etiology of CSF leak may be clas-
anterior table, posterior table, and the nasofrontal outflow sified by two main categories: traumatic and nontraumatic
tract (NFOT) (Fig. 24.1), as well as the existence of a pos- causes.
sible cerebrospinal fluid (CSF) leak. Approximately one- CSF leak may occur mainly as a result of trauma to the
third of the frontal sinus fractures are anterior table isolated anterior skull base (80%) or iatrogenic injury (10–15%).
fractures, and two-thirds are a combination of anterior table, Approximately 12–39% of anterior skull base fractures may
posterior table, and NFOT fractures. Isolated posterior table lead to the appearance of CSF, and 30% of them will settle
fractures are uncommon [10]. on the frontal sinus [13]. Endoscopic sinus surgery (EES)
Cerebrospinal fluid (CSF) is a clear, colorless fluid pro- may conduce to CSF leak in 16% of the patients, the pos-
duced by the choroid plexus of the brain ventricles. It cir- terior fovea ethmoidalis and the cribriform plate being the
culates from the ventricles to the subarachnoid space. CSF most injured areas (80%), followed by the frontal sinus in
helps maintain homeostasis, nutrient supply, and regulation a total of 8% [14]. In 4% of the patients, the CSF leak can
of intracranial pressure. Moreover, it provides a fluid buffer be secondary to congenital causes, such as encephalocele
that prevents mechanical damage of the brain tissue due to or meningoencephalocele, tumoral causes, or spontaneous
collision with the skull, in case of abrupt head movements causes. If no other cause for CSF is identified, patients are
and mild cranioencephalic trauma [11]. assumed to have a spontaneous CSF leak, which is associated
with a high CSF pressure, causing an increased hydrostatic
pressure at the weakest points of the skull base [15]. These
Supplementary Information The online version contains supplementary are more common in middle-aged women with obesity [body
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_24].
mass index (BMI) > 40 kg/m2], related to idiopathic intracra-
nial hypertension (IHH) [16].
S. Z. Saiz-Maza · A. Santamaría-Gadea · F. Mariño-Sánchez (*) The presence of CSF leak means that there is a com-
Rhinology and Skull Base Surgery Unit, Department of munication between the nasal cavity and the intracranial
Otorhinolaryngology, Hospital Universitario Ramón y Cajal,
space, with the attendant risk of meningitis and other cere-
Madrid, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 247
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_24
248 S. Z. Saiz-Maza et al.

Fig. 24.1  Frontal sinus anatomy: anterior table (blue), posterior table (red), and nasofrontal outflow tract (green)

bral complications. To prevent these life-threatening com- • Severely comminuted and displaced fractures may be
plications, confirmation and identification of the leak, as its managed with cranialization and/or obliteration of the
repair, is crucial to appropriate management. Frontal sinus frontal sinus or transnasal endoscopic repair.
cerebrospinal fluid (CSF) leaks represent a true challenge • ESS can be used for severely displaced or comminuted
in endoscopic sinonasal surgery (ESS), due to the diffi- posterior table fractures [21].
culty in approaching the area [17], but a successful closure • Open approaches are always preferred if neurosurgical
of frontal sinus CSF leaks is achieved in 92–97% of the surgery is required or if there are preexisting lacerations.
patients [18–20].
24.2.1.3 Frontal Fractures Involving
Nasofrontal Duct
24.2 Indications • Mild–moderate displaced/comminuted fractures with
functioning sinus may be managed with close observation.
24.2.1 Frontal Sinus Fractures • Nonfunctioning sinus requires surgical management.

24.2.1.1 Isolated Anterior Table Fractures

• Minimal displaced fractures may be managed with close 24.2.2 Frontal Sinus CSF Leak
observation.
• If cosmetic deformity occurs, it may be camouflaged in • Acute CSF leaks may be managed with conservative
the subacute setting (approximately 8  weeks after the management in the first 7 days.
injury). • Acute CSF leaks that persist after 7 days and chronic CSF
• Severely displaced or comminuted fractures may require leaks may require surgical management.
surgical management (open or endoscopic approach).

24.2.1.2 Posterior Table Fractures 24.3 Schematic Description (Anatomy

• Minimally displaced fractures with no nasofrontal duct and Expected Result)
involvement and no signs of CSF leak can be managed
with close observation. Frontal sinus is absent at birth, which is the last paranasal
• Mild comminuted displaced fractures may be considered sinus to develop, starting at 2  years of age. It is radiologi-
for sinus obliteration or transnasal endoscopic repair. cally detected at 8 years of age and usually reaches its adult
24  Treatment of Frontal Sinus Trauma and CSF Leaks 249

size at 15–20 years of age [22]. The frontal sinus is generally Physical examination is extremely important; however,
a bilateral structure, being described unilateral in 15% and the gold standard for the characterization of frontal sinus
absent in 8% of the population in the literature [23]. fractures is the high-resolution computed tomography (CT)
The anterior table of the frontal sinus is formed of a thick scan. Given the high association with other injuries, a CT
cortical bone, which makes it more resistant to fractures scan of the brain and neck may be considered. The anterior
than the other parts of the sinus. The inferior boundary of and posterior tables, as well as the patency of the NFOT,
the frontal sinus is formed, laterally for the orbit roof, and must be analyzed. Reconstruction in coronal and sagittal
medially for the NFOT. The frontal sinus drains toward the planes may be helpful [28].
middle meatus by the nasofrontal outflow tract, though a true Traditional approaches for frontal sinus fractures include
duct exists only in 15% of the patients, which is a simple bicoronal, supraciliar, or even direct forehead incisions. As
drainage conduct in the rest of them. The posterior table con- a result of the improvement of the endoscopy technology,
stitutes the anterior wall of the anterior cranial fossa; there- in the last two decades, less invasive techniques, such as
fore, any injury of this structure may potentially lead to a endoscopy-­assisted and especially transnasal approach, are
CSF leak [24]. becoming popular among the authors. Even so, the initial
The supraorbital and supratrochlear nerves, both branches approach should be individualized according to the extent
of the first division of the trigeminal nerve (ophthalmic nerve of the fracture, comminution, involvement of the posterior
V1), supply sensitive innervation to the skin of the upper eye- table and NFOT, and presence of a cerebrospinal fluid leak.
lid and forehead. The frontal branch of facial nerve crosses The following approaches to the frontal sinus have been
the upper face from lateral to medial; therefore, it may be described in Table 24.2:
injured during surgery [2].
24.4.1.1 Preexisting Lacerations
A preexisting laceration over the forehead can be used to
24.4 Preoperative Tips access the anterior table of the frontal sinus. However,
extending these lacerations or a second incision may be
24.4.1 Frontal Sinus Fractures occasionally necessary for adequate exposure of the bony
fragments [29].
Frontal sinus fractures should be contemplated in all patients
who suffer craniofacial trauma. They usually result from 24.4.1.2 Supraciliary Incision
high-energy trauma; consequently, the initial evaluation of A supraciliary incision along the superior border of the eye-
these patients should focus on the “ABCDE” approach [air- brow can be used for the reduction of anterior wall frontal
way maintenance with cervical spine protection, breathing sinus fractures, allowing a correct exposure of the fracture
with ventilation, circulation with hemorrhage control, dis- and the possibility of internal fixation, if necessary [30].
ability (neurological status), and exposure/environment]
[25]. The existence of intracranial injuries must be con- 24.4.1.3 Closed Approach: Percutaneous
sidered, due to the significant underlying forces involved, Reduction
requiring in such cases multidisciplinary management [26]. The percutaneous simple reduction is a minimally invasive
Once the patient is stable, a thorough examination should technique for isolated anterior table fractures. Different
be performed. It should include a neurological exam, focus- techniques have been described in the literature, includ-
ing on the sensibility and mobility of the upper face, palpa- ing screws and threaded K-Wires reduction [31, 32]. It
tion of the bone reliefs, and soft tissue of the forehead. It should be mentioned that for the success of these closed
should be recalled that, in early examinations, swelling may approaches, the fractures should not be too comminuted,
obscure physical findings [27]. Sensibility and mobility of two to three large bony fragments being admissible.
the upper face may be explored and documented in the initial Nonmechanical fixation and absence of direct vision, with
exam [23]. Physical findings suggestive of a fracture involv- risk of incomplete reduction, are former disadvantages of
ing the anterior table include soft tissue swelling, lacerations, these closed reduction techniques, while a good aesthetic
depression in the area, inability to raise the eyebrow, and result without scars, fewer complications, and decrease of
aesthetic deformities. When posterior table and nasofrontal recovery time represent the main advantages of these tech-
outflow tract are involved, these fractures may likely pres- niques [33].
ent depression of the supraorbital region, loss of sensibil-
ity in the distribution of the supraorbital and supratrochlear 24.4.1.4 Bicoronal Approach
nerves, and cerebrospinal fluid (CSF) leak. Any rhinorrhea in Coronal incisions are more extensive and aggressive; nowa-
a patient with a frontal sinus fracture must be assumed to be days, they have been relegated to complex sinus fractures
CSF leak until proven otherwise [2]. that cannot be managed expectantly or endoscopically. Still,
250 S. Z. Saiz-Maza et al.

Table 24.2  Indications, advantages, and disadvantages of the main approaches to frontal sinus fractures
Approach Indications Advantages Disadvantages
Preexisting lacerations Simple depressed noncomminuted No incisions Occasionally necessary to extend
anterior table fractures lacerations or second incisions
Supraciliary incision Simple fractures Minimal incision Scars, alopecia, scalp or forehead
Good exposure paresthesia
Possibility of internal fixation
Closed approach Simple, noncomminuted anterior Minimal incision Selected anterior table fractures
(percutaneous reduction) table fractures There may not be adequate reduction
Bicoronal approach Complex, large, comminuted Good exposure Scars, alopecia, scalp or forehead
fractures paresthesia
Increased time of recovery and
hospitalization
Endoscopic-assisted Simple fractures Two small incisions Specific surgical material is required
Good aesthetic results Technically more difficult
Endoscopic endonasal Simple and medial fractures No incisions Specific surgical material is required
Displaced fractures NFOT patency evaluated and Technically more difficult
Comminuted fractures treated at the same time
Lower rates of early and late
complications
Less recovery time and
hospitalization

bicoronal approach provides excellent exposure of the fron- as having a metallic or salty taste. The rhinorrhea may be
tal and the possibility of repairing complex comminuted constant or intermittent, and classically positional, usually
fractures [1]. aggravated by leaning forward. Depending on etiology,
it may be accompanied by a history of head trauma, nasal
24.4.1.5 Endoscopic-Assisted External obstruction, epistaxis, headache, or papilledema, among
Approach other clinical signs. Any clear nasal discharge should be
Endoscopic-assisted surgery requires two incisions behind investigated for CSF, especially after craniofacial trauma
the anterior hairline, in order to create two ports for the [37]. Physical examination of the nasal cavity by an endo-
endoscopy and the surgical instruments. This technique scope should be performed in all cases. Since rhinorrhea is
provides good exposure of the fracture with a less invasive a nonspecific sign, the presence of CSF must be confirmed
approach and better aesthetic results compared to other open by biochemical analysis, such as β-2 transferrin or β-trace
approaches such as the bicoronal incision [34]. protein. The site of the defect may be localized by the real-
ization of a high-resolution tomography, magnetic resonance
24.4.1.6 Endoscopic Endonasal Approach (EEA) cisternography, CT cisternography, or intrathecal fluorescein
Endoscopic management has been described as an effec- (IF) (Table 24.3) [38].
tive and less morbid approach for frontal sinus trauma,
being able to preserve the sinus function with a low rate of 24.4.2.1 Biochemical Analysis
both early and late complications [35]. Using endoscopic Biochemical analysis in patients with suspected CSF leak
endonasal reduction, the evaluation of nasofrontal outflow should be the first diagnosis study, before any other imaging
tract patency is possible intraoperatively, and the potential or invasive procedure, due to their high sensibility and speci-
obstruction is treated at the same time, because of the frontal ficity (Fig. 24.2). Currently, the most utilized markers are β-2
sinusotomy made for endoscopic access [10]. However, the transferrin and β-trace, both capable of detecting cerebrospi-
fracture should be medial to the mid pupillary line for good nal fluid when present in body secretions with a range of
exposure and reduction of the fractures [36]. To improve the concentration of 1–2.5% [39]. β-2 Transferrin is a glycopro-
visualization of the lateral part of the frontal sinus, a partial tein found exclusively in CSF and perilymph. Its absence in
removal of the orbital wall may be performed. nasal secretions makes its detection a marker for CSF leak.
This molecule is detected by immunofixation electrophore-
sis, which is time-consuming, expensive, and not available
24.4.2 Frontal Sinus Cerebrospinal in every laboratory [40]. The detection of β-trace protein is
Fluid (CSF) Leaks a faster and more accessible alternative for the diagnosis of
CSF leaks. β-Trace protein (prostaglandin D synthase) is one
A frontal sinus CSF leak may manifest clinically as unilat- of the most abundant proteins in CSF, not found in either
eral clear nasal rhinorrhea, which patients often describe nasal secretions [41].
24  Treatment of Frontal Sinus Trauma and CSF Leaks 251

Table 24.3  Advantages and disadvantages of main diagnosis tech- CT cisternogram is performed by instilling intrathecal con-
niques of CSF leaks trast and scanning the sinuses in the prone and supine posi-
Advantages Disadvantages tions. If a CSF leak is present, imaging will show leakage of
β-2 Transferrin • Noninvasive Nonlocalizing contrast adjacent to an osseous dehiscence. Due to high rates
• Accurate
of false negatives (often because of an inactive leak), CT cis-
β-Trace protein • Noninvasive Nonlocalizing
• Accurate ternography is currently relegated to specific scenarios, such
High-resolution • Non-invasive • Dehiscence may as multiple bony defects, in order to localize CSF leak [42].
CT • Localizing be present Radioactive cisternography can be used to localize intermit-
• Excellent bony detail without CSF tent CSF leak, but its utility is limited by a high rate of false
• Accessible leak
• Active CSF leak is not • Multiple bony
positives [38]. Magnetic resonance cisternogram uses intra-
necessary defects may be thecal gadolinium. Similar to CT cisternogram, a positive
described study shows extracranial fluid adjacent to an osseous dehis-
• Ionizing cence. A high-resolution CT is required for the interpretation
radiation
of the images [43]. Intraoperative use of intrathecal fluores-
CT • Localizing • Lumbar puncture
cisternogram • Excellent bony detail is required cein (ITF) is an adequate technique for detecting and local-
• False negatives izing a CSF leak simultaneously [44]. It should be reminded
• Active CSF that intrathecal fluorescein is not approved by the US Food
necessary for and Drug Administration (FDA), although low-­dose ITF has
diagnosis
• Ionizing been described as a safe and useful intraoperative procedure
radiation with minimal complications and successful localization of the
Radioactive • Localizing • Lumbar puncture leak in approximately 80% of the cases in the literature [45].
cisternography • Utility for intermittent is required
leaks • High rates of
false positives
• Not 24.5 Pearls and Potential Pitfalls
recommended
currently 24.5.1 Frontal Sinus Fractures
Magnetic • Useful if meningoceles • Poor bony detail
resonance or • Requires CT for
meningoencephaloceles interpretation • A 70° endoscope is indispensable for the correct visual-
• Nonionizing radiation ization and dissection of the frontal sinus when a transna-
Magnetic • Localizing • Poor bony detail sal repair is performed because many fractures may
resonance • Nonionizing radiation • Requires CT for extend laterally.
cisternogram interpretation
• In laterally extended fractures, resection of the superome-
Intrathecal • Localizing • Lumbar punction
fluorescein required dial orbital wall can improve access.
• FDA not • Mucosa should be exposed and completely removed, to
approved prevent subsequent mucocele formation.
• Adverse effects • Try to avoid damaging the centimeter superior to the
with high
concentration or orbital rim during open approaches, because it is the place
rapid injection where supraorbital and supratrochlear nerves exit, reduc-
ing the risk of frontal paresthesia.
• Particular attention must be paid to the irregular areas at
24.4.2.2 Diagnostic Imaging Tests the periphery of the sinus, especially in the supraorbital
High-resolution CT should be the first-line imaging because region. Extra time should be spent to ensure that mucosa
of its capacity for delineating osseous anatomy that may prove is completely removed from this area.
bony dehiscence (Fig. 24.3). The CSF leak does not have to • Draf III sinusotomy allows the recovery of the function of
be necessarily active to be able to identify bony dehiscence. the nasofrontal duct.
It should be reminded that not all dehiscence is associated
with a leak and that multiple bony defects may be described,
making it difficult to localize the site of the leak. This tech- 24.5.2 Frontal Sinus CSF Leak
nique has reported a sensitivity of 88–95% in localizing the
leak after CSF leak is confirmed by laboratory analysis [42]. • The use of intrathecal fluorescein guides us during sur-
Magnetic resonance imaging does not provide us with infor- gery, being able to locate the specific point of the leak.
mation about the bone framework; however, it can be very • Valsalva maneuvers at the end of the surgery can help to
useful in cases of meningoceles or meningoencephaloceles. verify the correct closure.
252 S. Z. Saiz-Maza et al.

Fig. 24.2  Frontal sinus CSF

leaks: author’s diagnosis
Suspected CSF leak
algorithm

Anamnesis
Physical examination
(including nasal
endoscopy and otoscopy)

Sufficient sample for Non sufficient sample for

laboratory laboratory

β-trace or β-2
transferrin

Negative Positive

Observation High-resolution CT

Site of defect Normal CT or meningo-or

meningoencephalocele Multiple defects
localized
suspected

Surgical repairment Skull base magnetic

resonance

Site of defect localized Non localizing

Diagnostic intrathecal
Surgical repairment fluorescein

Surgical repairment
24  Treatment of Frontal Sinus Trauma and CSF Leaks 253

a b

Fig. 24.3  Preoperative computed tomography images of cerebrospinal fluid leak, showing a bony defect (*) in the right frontal recess. (a) Frontal
view and (b) sagittal view

• As with lateral frontal sinus fractures, it may be necessary frontal outflow tract. Based on these key factors, in order to
to perform a superomedial orbital wall resection in order apply an algorithm of management, a classification of the
to reach lateral defects. frontal sinus fractures has been proposed [47]:
• It is important to remove the mucosa surrounding the
defect, in order to expose the bony framework. • Anterior table fractures.
• Posterior table fractures.
• Anterior and posterior table fractures (combined anterior
24.6 Management and Surgical Procedure and posterior wall fractures).
• “Through and through” fractures (skin to anterior cranial
24.6.1 Management of Frontal Sinus Fractures fossa)
• Fractures involving the nasofrontal duct.
In recent years, the trend is increasingly to be more conser-
vative in the treatment of these injuries, trying to preserve Transnasal endoscopic repair is preferred by the authors,
the functionality of the frontal sinus. The use of endoscopic except when the patient requires neurosurgical intervention
sinus surgery (ESS) for the reconstruction of these fractures or if there is a preexisting laceration that provides a good
is becoming more popular among the authors, in an attempt exposure of the fractures, factors in favor of open approaches.
to avoid other more aggressive surgical techniques, such as
obliteration and cranialization of the frontal sinus. A trans- 24.6.1.1 Management of Isolated Anterior
nasal endoscopic approach has advantages compared to Table Fractures
traditional approaches, such as decreased length of hospital- Isolated anterior table fractures represent 18–27% of frontal
ization, faster recovery time, and lack of incisions, providing sinus fractures (Fig. 24.4), being the most common presenta-
a better aesthetic result [46]. tion. In order to select the most appropriate management of
The main goals in the management of frontal sinus frac- an anterior wall fracture, the displacement and comminution
tures are creating a barrier between the intracranial space of the fracture, aesthetic deformities, patient’s comorbidi-
and frontal sinus, reestablishing the patency of the NFOT or ties, and surgeon’s preference and experience should be con-
obliterating the sinus cavity if it is not possible, preventing sidered. The traditional approach to isolated anterior table
early and delayed postoperative complications and restoring fractures is an open approach by a bicoronal incision, but
the frontal bone contour. With the aim of achieving these without injury of posterior wall or NFOT, several authors
principles, most authors have proposed some anatomic key have reported close observation as a safe strategy for these
factors that enable the selection of the most adequate treat- injuries, the surgical treatment being reserved for severely
ment for each patient and the classification of these fractures: displaced and comminuted fractures, in order to correct an
integrity of the posterior wall and involvement of the naso- aesthetic deformity (Fig. 24.5) [48].
254 S. Z. Saiz-Maza et al.

a b

Fig. 24.4  Preoperative computed tomography images of an anterior table fracture (*). (a) Sagittal view and (b) axial view

Fig. 24.5  Isolated anterior

table fractures: author’s
management algorithm
Isolated anterior table

Minimal displaced Observation Camouflage if

fractures (8 weeks) deformity
fractures

Open approaches
Severely displaced or
Reduction
comminuted fractures
Endoscopic endonasal
approach

Traditional Management options in the management of these deformities, which are

Minimal displaced fractures may be managed safely with generally well tolerated by patients [29].
close observation. In the acute stage, soft tissue edema Severely displaced or comminuted anterior wall fractures
may obscure an aesthetic deformity; therefore, a posterior may require surgical management by open reduction and
reevaluation of the bone contour is necessary. If treatment is internal fixation (ORIF), in order to fix and stabilize bony
required, camouflage of the cosmetic deformity can be per- fragments [2]. The bicoronal incision provides the largest
formed in the subacute setting, when edema is resolved and exposure and may be indicated in large comminuted frac-
bony fragments are ossified, approximately 8  weeks after tures. Mucosa should be exposed and completely removed,
the injury [29]. To camouflage the frontal contour, different to prevent subsequent mucocele formation. Posteriorly,
techniques employing a variety of materials are described once the fracture is completely exposed, a titanium mesh is
in the literature. Materials used for this purpose should ide- placed and secured with screws. As mentioned previously,
ally meet the following criteria: have a good biocompatibil- this traditional approach carries the associated morbidity of
ity, be easily malleable, and maintain a stable form with no scars, alopecia, and paresthesia. In consequence, there has
significant distortion over time [49]. Some of the materials been a development of minimally invasive techniques [48].
preferred by the authors are hydroxyapatite cement (HAC), The presence of lacerations that could be used to access
polymethyl methacrylate, polyether ether ketone (PEEK), the fracture site should be considered. Endoscopic-assisted
autologous bone, and titanium. The choice of materials approach represents a less invasive access through two sub-
depends on the shape of the defect, patient’s medical his- periosteal incisions behind the anterior hairline. A periosteal
tory and comorbidities, and surgeon experience [50]. Large elevator is inserted to create a cavity for a 30° endoscope. An
defects often require an open approach and graft placement, endoscopic dissector and scissors through the other port may
but smaller deformities may be repaired by endoscopy-­ approach the fracture site. After the reduction of the bony
assisted approaches. Percutaneous injectable fillers such as fragments, they are assembled by microplates (the micro-
collagen, hyaluronic acid, and fat injectables represent other plates are fixed through the incision) [34]. Other authors
24  Treatment of Frontal Sinus Trauma and CSF Leaks 255

have described percutaneous techniques for reduction with- to accurately reposition the bony fragments and to reduce
out fixation of simpler fractures, not too comminuted (2–3 the fracture. Resorbable packing (Surgicel®, Nasopore®,
fragments maximum) using screws or threaded K-Wires for MeroGel®) may be placed to support the fracture reduction
the reduction [31–33]. for severely comminuted fractures or unstable anterior table
reduction. Care should be taken not to injure the posterior
Endoscopic Endonasal Approach: Surgical Technique table [36, 51].
The procedure is performed under general anesthesia and
with the patient in supine position. Surgical patties soaked 24.6.1.2 Management of Posterior Table
in  local anesthetic and vasoconstrictor (lidocaine 1% with Fractures
adrenaline 1:1000) are placed in the nasal cavity in order to Posterior table fractures of the frontal sinus result from a
provide a decongested field while draping, and endoscopic high-energy injury (Fig. 24.6). Consequently, they are highly
equipment is prepared. For transnasal endoscopic repair, an associated with additional intracranial complications, and
anterior ethmoidectomy and a frontal sinusotomy are per- the management of these patients should be led by the con-
formed on the side of the injury, usually extended to a Draf trol of these acute complications [2]. Although there is no
IIb or Draf III, if required for good exposure of the fracture. consensus in the current literature for surgical repair, most
A 70° rigid endoscope is necessary for the correct visual- authors describe that the decision should be based on the
ization and dissection of the frontal sinus. A curved instru- degree of fracture comminution and displacement, as well as
ment, such as a frontal curette or a curved suction, is used the presence of a CSF leak (Fig. 24.7) [10].

a b

Fig. 24.6  Preoperative computed tomography images of an anterior (arrow) and posterior (*) table frontal sinus fracture. (a) Sagittal view and (b)
axial view

Functioning sinus Observation

Control with CT at
Not CSF leak
2 months and 1 year
Not functioning sinus ESS vs. Obliteration
Posterior table fractures

Mild-moderate
displaced/comminuted
fractures
Resolution Observation
Conservative
Severely CSF leak management
displaced/comminuted (7 days)
fractures Persistence ESS vs. Cranialization

Fig. 24.7  Posterior table fractures: author’s management algorithm

256 S. Z. Saiz-Maza et al.

Traditional Management left attached to the periosteum. Meticulous removal of the

Treatment of extensive fractures of the frontal sinus mucosa is made after using an elevator and diamond burr.
remains controversial. Historically, management options Following this, the mucosa lining the frontal recess is ele-
for posterior table fractures have included observation, vated, inverted, and pushed inferiorly to obstruct the naso-
open reduction with internal fixation (ORIF), obliteration frontal tract and the frontal sinus. They can be obstructed
of the frontal sinus, or removal of the posterior table with using pericranial flap, abdominal fat, temporalis muscle, fas-
cranialization [23]. cia, or synthetic materials such as hydroxyapatite or cartilage
Minimally displaced posterior table fractures with no chips. Finally, the anterior table is replaced and repaired with
nasofrontal duct involvement and no signs of CSF leak can fixation [52].
be managed with close follow-up [1]. Follow-up with CT Severely comminuted and displaced fractures have been
scans at 2 months and 1 year is appropriate for monitoring managed traditionally with cranialization and/or obliteration
possible long-term complications, such as mucocele forma- (Fig. 24.8) of the frontal sinus, often by a bicoronal approach
tion [3]. that allows full exposure of the bony fragments and internal
Mild comminuted displaced fractures with no CSF leak fixation. Donald and Bernstein first described cranialization
may be considered for sinus obliteration. Obliteration con- of the frontal sinus in 1978 [53]. This technique consists of
sists of eliminating the frontal sinus cavity while maintaining removing the posterior wall of the sinus and conscientious
both anterior and posterior walls. In this technique, a bicoro- elimination of the frontal sinus mucosa, allowing the frontal
nal flap is made, and the anterior wall is either removed or lobe dura to occupy the space and rest over the anterior table

a b

Fig. 24.8  Frontal sinus obliteration using abdominal fat (a) and frontal sinus cranialization (b)
24  Treatment of Frontal Sinus Trauma and CSF Leaks 257

and floor of the sinus, with the aim of achieving a complete tures are uncommon; they are usually associated with anterior
separation between the intracranial cavity and the sinonasal and/or posterior table fractures (Fig. 24.9). Injury to the fron-
tract below [54]. As with obliteration, the nasofrontal duct tal sinus outflow tract can lead to long-term complications
is obstructed, and the anterior wall is repaired and replaced. as a result of an anatomical obstruction, principally muco-
There is a risk of approximately 10–17% of complica- cele formation or chronic frontal sinusitis [58]. Traditionally,
tions after cranialization or obliteration including wound management has involved cranialization or obliteration of the
infections, CSF leaks, mucocele, intracranial infection, and sinus. Nowadays, more conservative techniques as primarily
aesthetic abnormalities. A low rate of mucocele formation transnasal endoscopic approach are becoming increasingly
and CSF leaks by transnasal endoscopic approach has been popular among the authors (Fig. 24.10) [23].
described in the literature [10].
Traditional Management
Endoscopic Endonasal Approach: Surgical Technique Nasofrontal duct obstruction is one of the key points of man-
After the preparation of the nasal cavity with patties, a Draf agement strategies in frontal sinus fractures. Conventional
IIb or Draf III is performed on the affected side, depending management has been centered in open approaches with
upon visualization and exposure. Mucosa of frontal sinus is
removed, and bony fragments are manually reduced using a
curved frontal curette or frontal suction tip. In comminuted
fractures, it is important to perform a careful removal of the
fragments from dura. Skull base repair is necessary if bone
fragment removal is performed. A flap with a superior ped-
icle, a nasoseptal flap (NSF) based on the posterior septal
artery, or other overlay graft such us Tutoplast® or Biodesign®
dural graft may be used following fracture reduction [55],
in case of simple fractures or if one to two bony fragments
have been removed. In the event of comminuted fractures
where more bony fragments have been removed and there is
a defect larger than 5 mm, underlay epidural repair should be
placed added to overlay graft [46]. If an anterior wall fracture
is associated, it should be repaired in the same surgical pro-
cedure. After reduction and repair of the skull base, Silastic®
stents are placed in the middle meatus and frontal sinus [56].

24.6.1.3 Management of Frontal Fractures

Involving Nasofrontal Duct
Frontal fractures involving the nasofrontal duct are seen in
approximately 25–50% of fractures involving the nasal– Fig. 24.9  Computed tomography images of an anterior (arrow) and
orbital–ethmoidal region [57]. Isolated nasofrontal duct frac- NFOT (*) fractures

Functioning sinus Observation

Mild-moderate
Fractures involving

Observation with
displaced/comminuted
nasofrontal duct

control CT at 2
fractures
months and 1 year
Functioning sinus
Non functioning sinus Endoscopic sinus surgery
Severely
displaced/comminuted
Endoscopic sinus surgery
fractures
Non functioning sinus

Fig. 24.10  Fracture involving nasofrontal ducts: author’s management algorithm

258 S. Z. Saiz-Maza et al.

bicoronal incision obliteration or cranialization of the sinus, 24.6.2.3 Endoscopic Endonasal Approach:
in order to prevent a mucocele formation. However, this does Surgical Technique
not eliminate the risk of complications, due to the difficulty Under general anesthesia and with the patient in supine
of eliminating all mucosa [10]. position, surgical patties soaked in  local anesthetic and
vasoconstrictor (lidocaine 1% with adrenaline 1:1000) are
Endoscopic Endonasal Approach placed in the nasal cavity. Intrathecal fluorescein (0.1  mL
In the case of isolated fractures of the nasofrontal duct, the of a 10% solution) is administered through lumbar punc-
endoscopic approach allows a maximum opening, from orbit ture, 30–60  min before general anesthesia. If intrathe-
to orbit (Draf III), with minimal comorbidity and without cal fluorescein is instilled, the patient should be placed in
external incisions. Furthermore, the correct functioning of Trendelenburg position for 30–60  min, making it easier
the frontal sinus duct is recovered, in contrast to the classic for fluorescein to reach the intracranial system. Draf IIa,
obliteration and cranialization approaches [23]. IIb, or III frontal sinusotomy is performed, with the aim of
achieving good exposure of the defect. Draf IIa is adequate
in patients with small medial defects, a Draf III being per-
24.6.2 Management of Frontal Sinus CSF formed in those with large, lateral, or multiple defects. To
Leaks improve the visualization of the lateral part of the sinus, it
may be necessary to drill the superomedial orbital wall. Once
24.6.2.1 Conservative Management at the frontal sinus, the surgeon changes to an angled endo-
Conservative management of acute CSF leaks has been pro- scope and curved instruments. The mucosa surrounding the
posed, mainly those implying head traumas. The purpose of defect and the rest of the frontal sinus must be removed to
conservative management in frontal sinus CSF leaks is pre- avoid mucocele formation. The choice of repair technique
venting an increase in intracranial pressure, in order to stop depends on the experience and preference of the surgeon.
leakage and allow the closure of the dural dehiscence [59]. All skull base reconstructions included multilayer closure
depending on the size of the defect. Triple-layer technique
• Bed rest. (intradural–epidural–extracranial) is used when the defect is
• Head elevation to 30°. large enough to fit an inlay graft (>5 mm) and a double-layer
• Avoid Valsalva maneuvers. one (epidural–extracranial) when it is small [17]. In small
• Strict control of blood pressure. defects and low CSF flow, it may be sufficient to use syn-
• Antibiotic prophylaxis. thetic material (Duragen®, Durapach®) or autologous mate-
rials (fascia lata, perichondrium, abdominal fat, etc.) in an
Authors show an 85% of spontaneous closure in trau- underlay fashion and covered by a free nasal mucosa graft.
matic CSF leaks over the first week. Additionally, a risk of However, in large defects (>1  cm) or with high CSF flow,
meningitis of 0.62% in the first 24 h, 5–11% during the first it is usually advisable to use multilayer reconstruction tech-
week and 55–88% after the first week post injury has been niques and pedicle flaps. First of all, it is recommended to
described in the literature. Consequently, conservative man- use synthetic or autologous materials in an underlay way, as
agement has been recommended for the first 7  days after in simple reconstruction. This material should be attempted
injury [59]. to be placed in the extradural space between the rest of the
meninges and the bone framework. One or more layers can
24.6.2.2 Traditional Surgical Management be placed in this position until the CSF leak is completely
Traditional management of frontal sinus CSF leaks has closed. This can be verified with intraoperative Valsalva
included open approaches, such as cranialization, to obliter- maneuvers. Then, the endonasal pedicle flap is placed on the
ate the sinus. However, the improvement in the transnasal bone framework. Given the position of the frontal sinus, the
technique in recent years has displaced these techniques, due use of flaps with a superior pedicle is usually the best option,
to their lower rate of complications and the reduction in the such as the anterior ethmoidal artery flap (Fig.  24.11), the
hospitalization length [60]. middle turbinate flap, the anteriorly pedicled lateral wall
24  Treatment of Frontal Sinus Trauma and CSF Leaks 259

• Nasal physiological saline irrigations are recommended

from the first postoperative day. They should be per-
formed at least three times per day until nasal cavity
mucosa is reepithelialized.
• After posterior table repair surgery, patients should be
monitored in an intensive care unit overnight. The length
of hospitalization should be individualized, depending on
the complexity of the fracture, the involvement of the pos-
terior wall and possibility of CSF leak, and the associa-
tion with brain injuries.
• In-office nasal debridement under endoscopic control is
performed 1 week after surgery, then the follow-up visits
can be scheduled every 2 weeks. The timing and number
of the consultations will be individualized, depending on
several factors, such as severity of crusting, presence of
synechiaes or infection, etc. If Silastic® stents were placed
during surgery, they should be removed on the first
debridement visit.

24.7.2 Frontal Sinus CSF Leak

• Full antibiotic coverage with high CSF penetration is

Fig. 24.11  Sagittal view of an anterior ethmoidal artery flap placed in administered intravenously during hospitalization, then
frontal sinus. The first vertical incision is made on the septal projection orally to complete 1 week postoperatively.
of the middle turbinate’s axilla. The posterior vertical incision is made • Nasal physiological saline irrigations are recommended
on the septal projection of the anterior border of the superior turbinate.
Inferiorly, the incision may be extended to the inferior meatus following the same protocol as for frontal sinus fracture.
• Patients should be monitored in an intensive care unit over-
night. The length of hospitalization is usually 2–3 days.
flap, or extranasally, the pericranial flap is also an option. • During hospitalization, patients should be on complete bed
The nasoseptal flap can also reach the frontal sinus despite rest, with head elevation to 30°, and Valsalva maneuvers
having a posterior pedicle. Synthetic materials such as should be avoided (laxatives can be used to prevent straining).
absorbable hemostat (Surgicel®, Nasopore®, MeroGel®) may • The indication of lumbar drain in the postoperative care is
be packed to stabilize the graft and improve the adherence to discussed in the literature. Some authors recommend it,
the defect site (Fig. 24.12 and Video 24.1). especially in posttraumatic CSF leaks. We avoid the use
of lumbar drain in our patients due to the risk of possible
complications (meningitis, pneumocephalus, and trans-
24.7 Postoperative Tips tentorial herniation) [18].
• In-office nasal debridement under endoscopic control is
24.7.1 Frontal Sinus Fractures performed 1 week after surgery, then follow-up visits can
be scheduled every 2 weeks. The timing and number of
• Full antibiotic coverage is administered intravenously consultations will be individualized.
during hospitalization, then orally to complete 3  weeks • Physical exercise should be avoided for 3  weeks post
postoperatively. operation.
260 S. Z. Saiz-Maza et al.

a b

c d

Fig. 24.12 (a) Anterior ethmoidal artery flap. The incision of the floor endoscopic examination of frontal sinus after CSF leak repair with
is extended laterally to inferior meatus. (b) Flap dissection. (c) View of anterior ethmoidal artery flap. IT inferior turbinate, NS nasal septum,
the defect in the frontal recess (arrow) using a 70° endoscope. AEAF anterior ethmoidal artery flap, RFS right frontal sinus, LFS left
(d) Anterior ethmoidal artery flap placed on the defect. (e) Postoperative frontal sinus, * previous defect
24  Treatment of Frontal Sinus Trauma and CSF Leaks 261

References 23. Guy WM, Brissett AE.  Contemporary management of trau-

matic fractures of the frontal sinus. Otolaryngol Clin North Am.
2013;46(5):733–48.
1. Kim IA, Boahene KD, Byrne PJ. Trauma in facial plastic surgery:
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 Treatment of Frontal Sinus Mucoceles
25
Gonzalo Díaz Tapia, Fernando González Galán,
Alvaro Sánchez Barrueco, Jessica Mireya Santillán Coello,
and José Miguel Villacampa Aubá

25.1 Introduction toms and can be particularly difficult to manage. It is esti-

mated that mucoceles have a potential for orbital and cranial
Mucoceles are benign cystic lesions that typically arise sec- erosion in 83.3% and 55.5% of cases, respectively [7].
ondary to an obstruction of the nasosinusal ostium. They Most mucoceles may be infected and, therefore, pres-
usually remain asymptomatic for a long time until they ent purulent discharge and are referred to as mucopyoceles.
develop potentially serious ocular and/or intracranial com- The lack of response to preoperative antibiotics reinforces
plications that hasten their diagnosis [1]. Otherwise, most the idea that antibiotics are ineffective as the sole treatment
are asymptomatic and are diagnosed as an incidental radio- option for mucoceles [8].
logical finding. Mucocele treatment is surgical [9]. The main goal involves
Triggering factors include fibrous dysplasia, chronic rhi- restoration of sinus drainage via endoscopic access or, oth-
nosinusitis, previous endoscopic sinus surgery, facial trauma erwise, affected sinus obliteration. Until the 1980s, muco-
or fractures, and sinonasal manifestations of systemic dis- celes were primarily treated by external approaches. The
eases [2]. Among these factors, allergic fungal rhinosinusitis main surgical techniques were the Lynch–Howarth incision
stands out as a notable predisposing factor for the develop- [10, 11] and the osteoplastic frontal sinusotomy described by
ment of mucoceles [3], without evidence of a direct relation- Bockmühl [12] and Weber et al. [13].
ship with other subtypes of chronic rhinosinusitis. Ostium At present, marsupialization of the mucocele by endo-
obstruction leads to a gradual accumulation of secretions, scopic surgery is considered the first choice of treatment,
causing progressive growth of the mucocele. Therefore, with low rates of morbidity and recurrence [9, 14–16]. By
many series link the occurrence of mucoceles to nasosinusal preserving the periosteum, it allows osteogenesis and bone
polyposis and/or a history of previous endoscopic surgery remodeling [15]. This approach offers an effective, mini-
[1], even many years after surgery. The estimated prevalence mally invasive treatment that is very well tolerated by the
after endoscopic surgery is 13.1% [4]. patient compared to open approaches [16]. In addition, the
Mucoceles occur mostly in adults, being rare in the pedi- endoscopic approach decreases intraoperative and postop-
atric population, in which case cystic fibrosis should be ruled erative morbidity, reduces operative time, allows a better
out [5]. The frontoethmoidal location is the most common, view of the lesion and surrounding anatomical structures,
but it can also occur in the sphenoid and maxillary sinuses. and decreases the chance of recurrence [17].
The terminology of giant frontal mucoceles is accepted in External approaches to the frontal sinus are still per-
the literature for those characterized by a significant intra- formed, alone or in combination with endoscopic surgery,
cranial or orbital extension [6]. These extensive lesions tend generally in lesions of the lateral wall, with difficult access,
to present with neurological and/or ophthalmological symp- or according to the surgeon’s experience, or in huge muco-
celes or giant mucoceles. However, endoscopic surgery with
Supplementary Information The online version contains supplementary endoscopic endonasal marsupialization has been confirmed
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_25]. to be a safe and effective approach, even in giant frontal
mucoceles with significant intracranial extension [15]. Thus,
a proper definition of the limits of an endoscopic procedure
G. Diaz Tapia · F. González Galán · A. Sánchez Barrueco
J. M. Santillán Coello J. M. Villacampa Aubá (*) is yet to be established [9, 18].
Fundación Jiménez Díaz University Hospital, Madrid, Spain Prandini et al. [19] and Primo et al. [20] demonstrated that
e-mail: [email protected]; [email protected]; clinical follow-up during the early stages of the disease may
[email protected]; [email protected];
[email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 263
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_25
264 G. Diaz Tapia et al.

be an option. Nevertheless, other reports recommended the the previously blocked frontal drainage pathway, restoring
complete elimination of mucoceles, even in the initial stage. the ventilation of the sinus and preventing recurrence of the
Recurrence rates in retrospective studies with groups that mucocele.
enrolled more than 80 patients are close to 10%, with a clear However, the risk factors for recurrence after marsupial-
decrease in this percentage in endoscopic approaches [21]. In ization are thought to be: performing surgery during acute
several long series of endoscopic approaches, the incidence infection, the presence of multiple mucoceles, and signifi-
of recurrence ranges from 0.9 to 2.2%. The recurrence rate in cant extension outside the sinus walls [26].
external approaches of the frontal sinus has been reported to
be 19% [22]. However, other studies showed no significant
statistical association between the type of surgery and recur- 25.3 Preoperative Tips
rence [23]. However, most publications do not specify the
recurrence rate depending on the approach chosen. Usually, 25.3.1 Individual Risk Factors
combined or open approaches are reserved for more complex
mucoceles with a greater possibility of recurrence, so it may In the doubt that the mucocele can solely be managed endo-
influence this analysis. scopically (e.g., location in the upper lateral region of the
sinus, major sclerosis on the floor of the sinus, restricted
endoscopic visualization, extensive intracranial extension),
25.2 Schematic Description (Anatomy: consent for external craniotomy with craniofacial surgery
Expected Results) should be obtained before surgery [27, 28]. The extent of the
lesion has to be analyzed in order to determine the necessity
The frontal sinus is the most complex of the paranasal of a multidisciplinary approach which includes the collabo-
sinuses due to its location and anatomical variations. Thus, ration with ophthalmologists and/or neurosurgeons. In addi-
mucoceles located in the frontal sinus pose a clinical and tion, the possibility of reconstructing bone defects should not
technical challenge given their relationship with the orbit be dismissed.
and the anterior cranial fossa, but also due to the anatomical
structures of the frontal recess.
Embryologically, the frontal sinus originates either as 25.3.2 Radiology
a direct expansion of the infundibulum or as an epithelial
migration of the anterior ethmoidal cells. In adults, the fron- It is important to assess the precise location and size of the
tal sinus drainage complex is an hourglass-shaped structure lesion by computed tomography (CT) and magnetic reso-
whose inferior portion is the frontal recess. The agger nasi nance imaging (MRI) to establish a surgical plan.
cells narrow down this recess anteriorly, and the union of its CT scan allows determining the regional anatomy and the
medial wall with the uncinate process forms a vertical bar, extent of the lesion. Special focus should be paid to patients
which is a useful landmark to achieve a correct identification with previous endoscopic surgery where important land-
of the frontal recess [24] (see Chap. 11). marks could be absent. MRI is useful in cases of intracranial
Due to its great variation, the anatomy of the frontal extension and in differential diagnosis (e.g., neoplasms, cho-
sinus can be classified (International Frontal Sinus Anatomy lesterol granuloma, dermoid cysts) [29].
Classification) based on three cell types [25] (see Chap. 6 for
a more detailed discussion of the IFAC):
25.3.3 Instrumentation
• Anterior cells that push the frontal drainage pathway
medial posterior or posteromedially: agger nasi cell, supra The instruments required for an endoscopic approach of
agger cell, supra agger frontal cell. a frontal sinus mucocele include the following: 30° and
• Posterior cells that push the drainage pathway anteriorly: 70° endoscopes, small rotating backbiting forceps, small
supra bulla cell, supra bulla frontal cell, supraorbital eth- (2.5  mm) straight and 45° upturned Blakesley forceps,
moid cell. endoscopic scissors, curettes (straight, 45° and 90° curette),
• Medial cells that push the drainage pathway laterally: Freer or Cottle elevator, 4-mm long curved suction, 10 or
frontal septal cell. 12 straight suction, small angled ball probe, microdebrider,
skull base burrs, and Colorado microdissection needle [29].
As reported in the literature, endoscopic marsupializa- If bicoronal access with frontal craniotomy is needed,
tion has become the approach of choice in the majority of additional instrumentation should be included: No. 15 scal-
patients attaining a satisfactory clinical outcome and a lower pel blade, self-retaining retractor, two-pronged skin hook,
rate of recurrence. This technique allows the widening of bipolar cautery, periosteal elevator, and 3–4 mm round burr.
25  Treatment of Frontal Sinus Mucoceles 265

25.4 Pearls and Potential Pitfalls Perform uncinectomy and middle meatal antrostomy.
Anterior and posterior ethmoidectomies are accomplished
Before the development of the actual endoscopes, open sur- in order to identify the lamina papyracea and the anterior
gery with radical removal of the mucocele was the elected ethmoid roof.
treatment. Nowadays, endoscopic approaches are the safest A Draf type IIB frontal sinusotomy is performed. The first
way to treat these lesions. The current tendencies are not on step is to determine the coronal level of the posterior frontal
radical removal but on marsupialization, especially on pri- sinus wall. This could be achieved through the natural frontal
mary surgery; the wider a mucocele is marsupialized, the ostium.
better. The frontal sinus ostium is identified by drawing a line
Due to the expansive nature of the mucoceles, the pos- parallel to the bony nasolacrimal duct and directed superiorly
terior wall or the floor of the frontal sinus may be broken, from the anterior border of the antrostomy (natural ostium
entering the anterior cranial cavity or the orbit. In those area) to a point 5–10  mm behind the anterior attachment
cases, it is important to consult a neurosurgeon and/or an (axilla) of the middle turbinate (Fig. 25.1) [30]. A ball probe
ophthalmologist to plan the best way to access and recon- is directed superolaterally, without pressure, and toward the
struct possible defects as needed. direction of the orbital roof [31].
Most frontal mucoceles can be reached with a 0° optic, If the frontal sinus ostium is difficult to identify, another
though adequate hyperextension of the head in the operating alternative is to visualize the coronal level of the poste-
room is essential. Some cases may require the aid of a 30° rior frontal sinus wall through a supraturbinal or transeptal
or a 45° optic. approach bypassing the frontal recess area [30] and drilling
When there is an infection of a mucocele (mucopyocele), a fenestration on the anterosuperior part of the middle turbi-
the endoscopic marsupialization for the drainage of the puru- nate [32] (see Chap. 13). Intraoperative navigation is recom-
lent cavity is better than open surgery. It is important to con- mended in these difficult cases in order to reduce the risk of
sider that in those infected cases, especially if osteomyelitis complications.
is associated, the scarring tissue can grow quickly and vastly, An incision with a Colorado-tip electro cautery is per-
leading to restenosis, so close monitoring on the postopera- formed in the mucosa above the middle turbinate up to
tive time is crucial. the roof of the nose (Fig.  25.2). Through this incision, the
In cases of lesions located lateral to the pupillary line, mucosa is elevated posteriorly with a Cottle elevator expos-
expanded endoscopic approaches such as Draf 3 fron- ing the underlying bone. Using a drill bur, remove the frontal
tal approach or even minimal open surgery (frontal osteo- process of the maxilla directly above the axilla. The burr is
plasty) may be needed. Open surgery is recommended only swept from the frontal ostium anterior across the frontal pro-
in selected cases, such as mucoceles associated with lateral cess of the maxilla removing both anterior and lateral bones
CSF leaks, or in cases where an orbit or a posterior wall (Figs.  25.3 and 25.4). This opens the access to the frontal
reconstruction is needed, or if a malignancy is involved in ostium in a funnel shape.
the origin of the mucocele. The unique absence of the bone
in some limits of the mucocele is not an indication of an
open access approach; in those cases, it is better just to do
an endoscopic marsupialization because the periosteum will
FM
guide the bone regeneration.
Some systemic pathologies such as Paget disease or
fibrous dysplasia may favor restenosis so a combined 5mm

approach could be more suitable. S MT

B
A
25.5 Step-by-Step Surgical Procedure
IT

As previously discussed, the most preferred approach to

treat sinus mucoceles is maximal endoscopic marsupializa-
tion [9].
The nose is topically anesthetized and decongested by
packing it with gauze soaked in tetracaine hydrochloride Fig. 25.1  Frontal sinus ostium identification. FM frontal mucocele, S
sphenoid sinus, MT middle turbinate, IT inferior turbinate, B ethmoid
with adrenaline. Using a 0° or 30° endoscope, both the nasal
bulla, A antrostomy, Oval nasolacrimal convexity, Solid arrow direction
cavities are assessed. Inferior turbinoplasty and septoplasty to identify frontal recess, Star anterior attachment (axilla) of the middle
should be considered to gain the greatest exposure. turbinate
266 G. Diaz Tapia et al.

FM

MT

IT

RMT
Fig. 25.2  Area of mucosal incision for a Draf IIb. MT middle turbi-
nate, IT inferior turbinate

Fig. 25.4  Resection of middle turbinate to access the frontal sinus

ostium. Coronal view. FM frontal mucocele, RMT right middle turbi-
nate, Oval area of resection to perform a Draf IIb

B
angled burr to remove the rest of the floor and the beak of the
frontal process of the maxilla [29].
A wider view of the frontal sinus could be achieved by
FM
NS removing the middle turbinate; this could be done at the
beginning or at the end of the procedure.
Depending of the surgeon preferences, a nonabsorbable
nasal packing can be inserted in the nasal cavity and can be
removed after 24–48 h.
MT

25.6 Postoperative Tips

The main objectives to prevent mucocele recurrence are

Fig. 25.3  Resection of middle turbinate to access the frontal sinus promoting mucosal healing and keeping the paranasal
ostium. Endoscopic view of the right nasal cavity. FM frontal muco- sinus permeable. In general, recurrences are secondary to
cele, MT middle turbinate, NS nasal septum, B burr obstruction of normal sinus mucociliar drainage, usually
in conjunction with epithelial disruptions such as prior
Exenteration of the cells leads to the access of the muco- surgery or trauma. Mucocele recurrence can occur even
cele. The mucocele sac is opened, and the content is imme- decades after initial treatment, and therefore, long-term
diately drained. The mucocele sac is opened wide to achieve follow-up is required, providing adequate counseling to
maximal marsupialization forestalling early closure and patients. When the endoscopic postoperative control is
recurrence of the lesion. inadequate, radiological control (mainly CT scan) can be
Complete the Draf type IIB frontal sinusotomy by identi- performed.
fying the anterior lip of the frontal ostium and removing the Therefore, cures must be periodic (weekly should be
bone anterior to it (which forms the frontal beak). Drill in a the habitual option), seeking the elimination of nonadhered
superior and lateral direction to avoid endangering the skull crusts, avoiding infections and abnormal scarring that lead
base. Drilling continues superiorly until the floor of the fron- to adhesions, synechiae, or ostium stenosis, for as long as
tal sinus is entered, and the frontal sinus can be seen. Use an needed to achieve optimal results [33].
25  Treatment of Frontal Sinus Mucoceles 267

To promote re-epithelialization of the frontal ostium, 6. Lund VJ, Henderson B, Song Y.  Involvement of cytokines and
vascular adhesion receptors in the pathology of fronto-ethmoidal
some authors place mucosa grafts from the middle turbinate
mucocoeles. Acta Otolaryngol. 1993;113(4):540–6.
[34]. Other mucosal grafts may also be used, such as mucosa 7. Har-El G. Endoscopic management of 108 sinus mucoceles. Laryn-
of the floor of the nasal fossa or inferior turbinate tail, if goscope. 2001;111(12):2131–4.
middle turbinate grafts are not available. In addition, some 8. Plantier DB, Neto DB, Pinna FR, Voegels RL. Mucocele: clinical
characteristics and outcomes in 46 operated patients. Int Arch Oto-
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rhinolaryngol. 2019;23(1):88–91.
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[35, 36]. sal sinus mucocoeles: efficacy of endonasal micro-endoscopic
Nasal irrigations with saline solution should be frequent, management and long-term results of 185 patients. Rhinology.
2006;44(1):62–7.
4–5 times a day. The use of devices that increase the flow of
10. Lynch RC. The technique of a radical frontal sinus operation which
the solution and favor the removal of debris should be pro- has given me the best results. Laryngoscope. 1921;31:1–5.
moted. Proper nasal irrigation technique should be taught, 11. Howarth WG. Mucocele and pyocele of the nasal accessory sinuses.
ensuring that the saline solution reaches the surgical site. In Lancet. 1921;2:744–6.
12. Bockmühl U.  Osteoplastic frontal sinusotomy and reconstruction
addition, it is recommended to use lubricating agents that
of frontal defects. In: Kountakis S, Senior B, Draf W, editors. The
promote scab shedding and healing (nasal petroleum jelly, frontal sinus. Berlin: Springer; 2005. p. 281–9.
hyaluronic acid, etc.). Topical corticosteroids that can reduce 13. Weber R, Draf W, Keerl R, Kahle G, Schinzel S, Thomann S, Law-
edema and accelerate the healing process, so might be rec- son W. Osteoplastic frontal sinus surgery with fat obliteration: tech-
nique and long-term results using magnetic resonance imaging in
ommended for at least 6 months, and they can start sooner
82 operations. Laryngoscope. 2000;110(6):1037–44.
in the postop period if they are dissolved inside the nasal 14. Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith
irrigations. MM. Endoscopic sinus surgery for mucoceles: a viable alternative.
Although postoperative infections are not frequent, it has Laryngoscope. 1989;99(9):885–95.
15. Lund VJ. Endoscopic management of paranasal sinus mucocoeles.
been recommended to take sample culture and adjust treat-
J Laryngol Otol. 1998;112(1):36–40.
ment plan according to the results of the microbiological cul- 16. Serrano E, Klossek JM, Percodani J, Yardeni E, Dufour X.  Sur-
ture in the immediate postoperative period [6, 7]. In the gical management of paranasal sinus mucoceles: a long-term
authors’ view, nowadays, it is not recommended unless signs study of 60 cases. Otolaryngol Head Neck Surg. 2004;131(1):
133–40.
of local infection appear.
17. Dhepnorrarat RC, Subramaniam S, Sethi DS. Endoscopic surgery
for fronto-ethmoidal mucoceles: a 15-year experience. Otolaryngol
Head Neck Surg. 2012;147(2):345–50.
In our experience, the approach should be adapted to 18. Horowitz G, Amit M, Ben-Ari O, Gil Z, Abergel A, Margalit N,
each case and not opted for an extensive approach et  al. Cranialization of the frontal sinus for secondary mucocele
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(Draf III type) as a first measure. The standardization
One. 2013;8(12):e83820.
of periodic postoperative cures can help to avoid post- 19. Prandini MN, Tella OI, Lacanna SN, et  al. Giant mucoceles:

operative stenosis and recurrences. These cures can be neurosurgical view. Report of two cases. Arq Neuropsiquiatr.
performed in the office under local anesthesia with 2005;63:535–8.
20. Primo OVB, Lourenço EA, Pandini FE, et al. Mucopiocele de seio
good tolerance by the patient.
frontal: relato de caso. Perspect Méd. 2008;20:25–9.
21. Obeso S, Llorente JL, Pablo Rodrigo JP, Sánchez R, Mancebo G,
Suárez C. Paranasal sinuses mucoceles. Our experience in 72. Acta
Otorrinolaringol Esp. 2009;60(5):332–9.
22. Santos PLD, Chihara LL, Alcalde LFA, Masalskas BF, Sant'Ana E,
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Bonfils P.  Sinus mucocele: natural history and long-term recur- Cordova JL.  Experience in the surgical treatment of paranasal
rence rate. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(3): sinus mucoceles in a university hospital. Cir Cir. 2017;85(1):
125–30. 4–11.
2. Capra GG, Carbone PN, Mullin DP.  Paranasal sinus mucocele. 24. Dassi CS, Demarco FR, Mangussi-Gomes J, Weber R, Balsalo-
Head Neck Pathol. 2012;6(3):369–72. bre L, Stamm AC.  The frontal sinus and frontal recess: anatomi-
3. Ryan MW.  Allergic fungal rhinosinusitis. Otolaryngol Clin North cal, radiological and surgical concepts. Int Arch Otorhinolaryngol.
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P. Mucocele development after endoscopic sinus surgery for nasal Citardi MJ, et al. The international frontal sinus anatomy classifi-
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29.
Wormald P-J.  Endoscopic sinus surgery. Anatomy, three-­ extra nasal approach for the surgical treatment of severely diseased
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 Treatment of Frontal Sinus Osteomas
26
Erin Reilly and Roy Casiano

26.1 Introduction while symptomatic lesions should be considered for surgical

excision. Before offering surgery, it is important to exclude
Osteomas are the most common nonepithelial benign tumors all other explanations for the presenting symptoms. Those
of the paranasal sinuses. They typically occur between the osteomas that are watched should have a repeat CT scan in
second and fifth decade of life and are two to three times 6 months to 1 year.
more common in males. Sinonasal osteomas have been Once surgical removal has been advised, the type of sur-
found incidentally in 3% of CT scans and grow slowly at a gical approach is then established. For a frontal sinus oste-
rate of 0.91  mm/year [1]. Less than 10% of all osteomas oma, parameters such as location, size, extension, and frontal
become clinically symptomatic, depending on the size and recess anatomy have been proposed as necessary to consider
location of the lesion [2]. The most frequent symptoms are when determining the type of operative procedure. Before
headache, facial pain, or pressure likely due to the compres- the development of endoscopic surgery, the gold standard for
sion of surrounding structures, but the secondary formation the removal of sinonasal osteomas was through an external
of sinusitis, mucoceles, and orbital or intracranial complica- approach, such as an open osteoplastic flap with or without
tions can occur as well. Osteomas of the frontal sinus (>50%) obliteration for lesions of the frontal sinus or a lateral rhi-
are the most common, followed by the ethmoid sinus, while notomy and external ethmoidectomy for tumors of the eth-
maxillary and sphenoid are rare. The exact cause of osteo- moid cavity. Exclusive of symptoms, surgery was initially
mas is unknown, but their etiology has been suggested to proposed for osteomas that extended beyond the frontal
originate from a developmental, traumatic, or infective ori- sinus boundaries, were enlarging based on subsequent radio-
gin. CT is the imaging modality of choice for bony lesions, logic examination, located adjacent to the nasofrontal duct,
and osteomas radiologically appear as well-circumscribed causing chronic sinusitis, and all osteomas of the ethmoid
masses with both hyperostotic (high signal) and spongiotic sinus irrespective of size due to risk of extension into the
(low signal) components that do not enhance with contrast. orbit [4]. Around the same time, Smith et al. suggested that
An MRI is recommended if there is invasion of the intracra- osteomas which occupy greater than 50% of the frontal sinus
nial and orbital cavities. volume be removed [5]. As the endoscopic technique
emerged, surgical indications shifted from what should be
resected to how. Schick et al. stressed that a prerequisite for
26.2 Indications complete endonasal tumor resection was adequate access to
all tumor confines [6]. They outlined exclusion criteria for
The management of benign sinonasal masses should follow the purely endoscopic removal of frontoethmoidal osteomas,
a balanced algorithm of the need for resection weighed which consist of extranasal extension, an anteroposterior
against the morbidity of surgery [3]. It is generally agreed diameter of the frontal sinus outflow <10 mm, lateral exten-
upon that asymptomatic sinonasal osteomas can be observed sion beyond a virtual sagittal plane through the lamina papy-
racea, and an attachment site that was not of the inferior
Supplementary Information The online version contains supplementary posterior frontal sinus wall. Several other authors have cor-
material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_26]. roborated these criteria [7, 8]. In 2005, Chiu et al. developed
a grading system to assist with the decision of whether to
E. Reilly (*) · R. Casiano proceed with an endoscopic or open approach [9]. They
Department of Otolaryngology, University of Miami Hospital, identified three variables that affect the ability to remove an
Miami, FL, USA
osteoma endoscopically: location of the base attachment,
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 269
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_26
270 E. Reilly and R. Casiano

location in relation to the sagittal plane through the lamina bone with minimal heat and bone dust production that leads
papyracea, and the anterior–posterior diameter of the lesion to less damage of surrounding mucosal surfaces [13]. Other
compared to the anterior–posterior dimension of the frontal authors have developed new classification systems or
recess. Grade I lesions are medial to the virtual sagittal plane expanded on the current grading system to better define the
of the lamina papyracea, attached to the posterior–inferior limitations of the endoscopic approach [14, 15]. Nonetheless,
aspect of the frontal recess, and occupy <75% of the ante- we have not reached a universal consensus on the surgical
rior–posterior dimension of the frontal recess. Grade II management of frontal sinus osteomas. The purely endo-
lesions are the same as grade I except they occupy >75% of scopic resection of large, adversely located osteomas of the
the anterior–posterior dimension of the frontal recess. Grade frontal sinus is becoming increasingly possible, but there is
III lesions have a base of attachment located at the anterior or still a role for the open approach in those cases naturally lim-
superior aspect of the frontal sinus and/or extend lateral to ited by individual anatomic conditions.
the virtual sagittal plane of the lamina papyracea. Grade IV
lesions fill the entire frontal sinus. The authors advocate that
grade I lesions are amenable to endoscopic removal. Grade II 26.3 Schematic Description (Anatomy:
tumors push the limits of endoscopic resection as they have Expected Result)
an amenable location but are large relative to the size of the
frontal recess. These are lesions for which an extended fron- Macroscopically, osteomas are usually round or oval, with a
tal sinus procedure is usually needed, such as a Draf 2b or 3. broad or stalk-like attachment to the underlying bone that is
Grade III and IV osteomas are recommended to be removed covered with periosteum and mucosa. They are usually
through an open approach, as endoscopic excision can be smooth and have bosselated surfaces, marked by rounded
“dangerous.” Over the past decade, however, these previ- protuberances. Osteomas typically conform to the internal
ously recognized limits for endoscopic resection have been contour of the sinus of origin, as shown in Fig. 26.1; how-
exceeded. ever, they can distort or grow past the normal borders of a
Several authors have since published on the endoscopic sinus cavity.
removal of grade III and IV osteomas [10–12]. They identi-
fied four factors that have facilitated the success of the endo-
nasal approach: the evolution of telescopes with various 26.4 Preoperative Tips
angles of views, enhanced endoscopic instrumentation,
refinement of surgical techniques and expertise, and the Gardner’s syndrome is an autosomal dominant hereditary
development of navigation. Navigational systems aid the disorder characterized by a clinical triad of intestinal polypo-
removal of higher grade lesions where the boundaries of the sis, head and neck osteomas, and soft tissue tumors. The sig-
osteoma and the walls of the frontal sinus are indistinguish- nificance of Gardner’s syndrome lies in the high propensity
able. The modified Lothrop procedure allows access from of polyps to undergo malignant change. It has been sug-
the contralateral nasal cavity to reach disease that is more gested that the development of clinically evident osteomas
laterally located within the frontal sinus. Pagella et al. sug- precede the diagnosis of gastrointestinal polyposis by an
gests using an ultrasound bone emulsifier (i.e., Sonopet) as average of 17 years. While not every patient with an osteoma
an alternative to standard straight and angled drilling burs. has Gardner’s syndrome, it may be beneficial to ask about
The advantage of this instrument is a selective dissection of gastrointestinal symptoms or a family history of colonic pol-

Fig. 26.1  On left, arrow points to osteoma within frontal outflow tract. In middle, osteoma is removed en bloc with Kerrison rongeur. On right,
view of frontal outflow tract after osteoma is completely removed
26  Treatment of Frontal Sinus Osteomas 271

yps or cancer. Further inquiry should definitely be performed 424 cases the recurrence rate was 1.7% [19]. Therefore, most
if the patient has multiple osteomas, including the paranasal of the literature advocates for a complete surgical removal of
sinuses, mandible, and skull. Suspected patients should have the osteoma when safely possible.
a complete work-up including referral to a specialist who can When removing an osteoma endoscopically, the lesion is
perform a lower gastrointestinal tract endoscopy, barium often rocked back and forth to fracture it at its base of attach-
enema imaging, and genetic testing [16]. ment. If this base is located superiorly in the frontal sinus, a
The most important component in managing frontal sinus defect created in the posterior wall with a resultant CSF leak
osteomas is proper surgical planning. This includes careful will be difficult to repair. Furthermore, too-early separation
analysis of the patient’s CT scan to determine the optimal of the base of the lesion from the frontal sinus wall before
approach for resection. The extension of surgical dissection debulking should be avoided, since the detached part may
is proportional to the surgical necessity and is tailored to prove to be too bulky to be evacuated through the frontal
each individual patient. Although guidelines regarding the sinus ostium [2].
endoscopic resectability of osteomas exist, technical require- Due to the creation of a circumferential raw bony surface,
ments and surgeon experience should also be considered there is a higher risk for postoperative narrowing of the fron-
[17]. If there is any doubt of the appropriateness of the endo- tal sinus neo-ostium (50%) compared to a routine modified
nasal approach, the patient should be informed about the Lothrop procedure (30%). To prevent this complication,
potential use of a combined external approach some authors favor the use of a mucosal flap to line the cav-
preoperatively. ity and help maintain patency [10, 14]. Other authors have
suggested using silastic stents when more than 40% of the
frontal sinus mucosa is removed, for as long as 6 months to
26.5 Pearls and Pitfalls 1 year, to prevent postoperative stenosis [12].

Advocates of the traditional open approach cite a wider

exposure, easier dissection, and better ability to handle 26.6 Step-by-Step Surgical Procedure
bleeding or a CSF leak. Disadvantages include longer length
of stay, increased postoperative pain and paresthesias, as The endoscopic approach begins with bilateral nasal endos-
well as poor cosmesis due to external skin incisions and copy with a 30° camera and injection of local anesthetic.
increased risk of wound infection and frontal bossing [18]. If Inferior turbinate reduction and/or septoplasty are performed
frontal sinus obliteration is also performed, the failure rate is as needed for instrument access. Starting on the ipsilateral
extremely high (30%) secondary to degeneration of the fat side of the osteoma, the uncinate process is taken down in its
and mucocele formation. This makes revision surgery par- entirety. A maxillary antrostomy is performed with widening
ticularly challenging [10]. On the other hand, the endoscopic of the natural ostium. The superior border of the natural
approach has been shown to reduce patient morbidity, both ostium demarcates the junction of the medial orbital floor
intraoperatively and postoperatively. This technique main- with the lamina papyracea, which serves as an important
tains normal mucociliary clearance and the frontal sinus out- landmark for further dissection. At minimum, an anterior
flow tract. However, overall operative time may be longer, ethmoidectomy is then completed. A posterior ethmoidec-
and a surgeon who can perform extended frontal sinus proce- tomy and sphenoidotomy can be performed if chronic sinus
dures such as a Draf 2b or 3 is required [19]. Frontal sinus disease is also present. The roof of the superior-most supra-
trephination is a great adjunct to standard endoscopic sur- bullar and agger nasi cells should be removed, so that the
gery, as it allows the surgeon to access pathology from an frontal sinus ostium can be identified. The 30° endoscope is
additional viewpoint, using a small and well-camouflaged switched to a 70° optic at this point for better visualization.
incision. Trephination is ideal for cases in which a purely Depending on the location of the osteoma, the frontal sinus
endoscopic approach is not feasible and an open osteoplastic ostium can then be entered. Palpation of the posterior frontal
flap procedure is too aggressive. infundibulum wall, with an angled ball probe, identifies the
It has been suggested that the growth of an osteoma origi- coronal plane behind which the anterior skull base is located.
nates from a central vascular and osteoblastic core. According The outflow tract can be widened anteriorly by curetting or
to this theory, complete excision of the core and leaving a using a Kerrison rongeur to remove the thick bone that forms
remnant of peripheral bone behind in order to prevent com- the nasofrontal beak. The frontal sinus floor can also be
plications such as dural exposure or cerebrospinal fluid drilled down with a straight or angled (70°) cutting bur. This
(CSF) leak would not lead to recurrence [20]. However, there will result in a Draf type 2a. If the lesion can be accessed
have been a few reports of regrowth, which suggests that any through the unilateral nostril, then the central part of the
remaining abnormal bone may contribute to recurrence [21, tumor is drilled out through a cavitation technique. The
22]. A systematic review by Karunaratne et al. found that in thinned external bony shells can then be removed with for-
272 E. Reilly and R. Casiano

ceps or curettes, and the base of the tumor can be smoothed necessary to fit the endoscope and any instruments needed to
down with a 70° angled diamond bur. If the lesion is attached remove the osteoma. The bony defect can then be covered
more laterally within the frontal sinus and an angled drill with a small piece of titanium mesh to prevent soft tissue
needs additional room medially, then the anterior–superior from herniating into the sinus (Fig.  26.2). An osteoplastic
aspect of the middle turbinate can be taken down for supple- flap is typically indicated for larger osteomas, as it provides
mentary access. The bony medial margin of the frontal a direct view of the frontal sinus proper and allows bimanual
infundibular opening is also the superior point of insertion of instrumentation. Factors that need to be considered with this
the middle turbinate vertical lamella and can be removed technique are location of the skin incision, unilateral versus
with curettes or powered instruments. Care must be taken to bilateral sinus entry, status of the posterior table and frontal
leave the middle turbinate vertical lamella attachment infe- recess, and obliteration of the sinus. A coronal, eyebrow,
rior to the floor of the frontal sinus intact, as it is in continuity midforehead, or gullwing incision have all been previously
with the lateral lamella of the cribriform plate and medial described. The scalp is dissected down to bone at the level of
fovea ethmoidalis at this level. This will result in a Draf type the supraorbital rim, with care to preserve the overlying peri-
2b approach. osteum for a pericranial flap as well as its vasculature (supra-
If the osteoma cannot be accessed entirely through a uni- trochlear and supraorbital neurovascular bundles). A section
lateral approach or if it involves the contralateral frontal of bone from the anterior table of the frontal sinus is then
sinus, a Draf 3 or modified Lothrop procedure is required. mapped out and removed, or alternatively outfractured and
The modified Lothrop can be performed through a midline hinged anterioinferiorly. This is usually accomplished by
transseptal approach (“outside-in”) or connected to a con- making several pilot holes with a small bur and then using a
tralateral 2a frontal sinusotomy (“inside-out”). The deci- sagittal saw in a beveled fashion to connect the pilot holes.
sion between which of these techniques to use depends on The saw cuts should be beveled inward to enable the bone
the location of the osteoma and whether the normal frontal flap to sit flat against the remaining calvarium without falling
sinus ostium can be identified. An anterosuperior septec- into the cavity (Fig. 26.3). At the end of the procedure, the
tomy is performed, facilitating exposure and introduction anterior table bone flap is replaced and resecured to the fron-
of instrumentation from both the sides of the nose. The tal bone.
level of the cribriform plate corresponds to the coronal Obliteration should be considered if the frontal recess is
plane of the posterior wall of the frontal sinus infundibu- disturbed or more than half of the frontal sinus mucosa is
lum. Posterior to this plane, the potential is increased for sacrificed. It may be avoided, however, if the frontal recess is
inadvertent intracranial penetration or injury to the olfac- addressed through a combined endoscopic approach.
tory nerve fibers. The coronal plane of the posterior wall Obliteration can be problematic in cases with preoperative
of the frontal sinus infundibulum and bur are always kept erosion of the posterior table bone, where the sinus mucosa
visualized at all times, as one proceeds across the mid- is directly overlying the dura, as the procedure requires all
line to the opposite side or superiorly through the frontal mucosa to be removed completely from both the sinus and
sinus along the intersinus septum. The perpendicular plate the bone flap. In cases where surgical removal of the poste-
may be resected all the way to the nasal bones and nasion rior table bone is required, the exposed dura simply remuco-
dermis, enlarging the neo-ostium anteriorly. Additional salizes. This is shown in Fig.  26.4, which illustrates the
enlargement toward the orbit and supracanthal dermis is postoperative result following removal of the posterior table
performed to widen the lateral dimensions of the opening, for a grade IV osteoma. If a small dural tear with CSF leak is
providing greater access to the supraorbital recesses of the encountered, an inlay dural substitute or mucosal onlay graft
frontal sinus as seen from the contralateral side. Once a may be sufficient for repair. If there is a significantly larger
common frontal sinus cavity is obtained, osteoma removal CSF leak, cranialization with a pericranial flap should be
may proceed as stated above. employed.
There are several options for an open approach to the Computer-guided stereotactic intraoperative navigation
frontal sinus, and they can be employed alone or in combina- can be employed at the discretion of the surgeon but is often
tion with an endoscopic procedure working from “above and beneficial. Navigation is particularly useful in cases where
below.” The two main techniques, with various modifica- the orbit or skull base is involved, for revision surgery and in
tions, are frontal sinus trephination and the osteoplastic flap. the identification of the osteoma’s base of attachment. For an
A simple trephine can be made through an eyebrow, upper external approach, navigation or transillumination from
eyelid crease, or Lynch incision. Dissection is performed below has replaced the 6-ft Caldwell view radiograph that
down to periosteum, and a 5–15 mm hole in the anterior table was traditionally used to map out the frontal sinus when cre-
or frontal sinus floor is created. The hole can be enlarged as ating an osteoplastic flap.
26  Treatment of Frontal Sinus Osteomas 273

Opening superior anterior table of frontal sinus simultaneously

visualizing through an intranasal endoscope (Draf II or III)
a b e
Transverse crease Anterior Opening lateral anterior table of the frontals sinus
forehead incision #1 frontal
Frontal
table Lateral frontal
Medial brow sinus
opening opening Bony
incision #2 Bur septation

Burr

Lateral brow
incision #3

Opening medial Endoscope

c
anterior table of Endoscope
the frontal sinus

Mass f Infraorbital opening (enlarged trephination)

into the frontal sinus
d
Titanium Frontal
Burr sinus
mesh
Mass

Opening

Bur

Endoscope

Fig. 26.2  Various incision types and entry points for a combined open orbital bony opening (b, c, e, f). The defect can then be covered with a
and endoscopic approach. The frontal sinus can be accessed through a titanium mesh plate (d). Drawings obtained from Casiano R, Endoscopic
forehead or brow incision (a) with an anterior, medial, lateral, or infra- Sinonasal Dissection Guide, second Edition, Thieme; 2017

26.7 Postoperative Tips approach also need topical wound care of the incision site
and suture removal if required.
Postoperative imaging is not routinely recommended due to Follow-up is important for these patients regardless of the
the ease of endoscopic surveillance. In lesions with signifi- approach. For cases managed endoscopically, there is a high
cant extension, involvement of critical structures (skull base, risk of stenosis of the frontal outflow tract. Early intervention
orbit) or rapid tumor growth, a follow-up CT scan is advis- may prevent more severe complications such as mucocele
able 12 months after primary surgery [17]. formation. Open approaches are at greater risk of cosmetic
For those patients who have undergone an endoscopic deformities secondary to bone resorption, bone migration,
approach, postoperative care is the same as routine sinus sur- irregular contouring, or poor plating. In patients who have
gery. Saline rinses should be started on postoperative day 1 undergone obliteration, MRI is the imaging modality of
and standard sinus precautions maintained. In cases of fron- choice; however, it may be limited in its ability to detect small
tal sinusitis, antibiotics should be targeted toward cultures recurrent mucoceles and to differentiate vital adipose tissue
obtained intraoperatively. For cases with a CSF leak or status from oil cysts due to fat necrosis or granulation tissue [23]. In
post obliteration, additional antibiotics are employed at the addition, it is essential to recognize and counsel these patients
discretion of the surgeon. Patients who have had an open that problems can develop even 10–20 years later.
274 E. Reilly and R. Casiano

Endoscope
transilluminating
Frontal c Frontal through
sinus sinus trephination

1b Sagittal
a saw

d
Forehead Frontal
Bicoronal
crease sinus
incision
incision (anterior
table)
removal
with
sagittal
saw

e
2b

Brow
incision
Frontal
sinus

After frontal
sinus anterior
table removal

Fig. 26.3  An osteoplastic flap can be performed through several differ- tal sinus can then be fully visualized (e). Drawings obtained from
ent incisions as shown in (a, b). The frontal sinus can then be mapped Casiano R, Endoscopic Sinonasal Dissection Guide, second Edition,
out through navigation or transillumination with an endoscope and used Thieme; 2017
to guide the bony cuts using a sagittal saw (c, d). The inside of the fron-

Fig. 26.4  On the left, preoperative axial CT scan of a grade IV oste- plastic flap has been replaced and plated, and the posterior table is
oma filling the left frontal sinus. On the right, postoperative axial CT absent with remucosalization of the underlying dura
scan following a combined open and endoscopic approach. The osteo-
26  Treatment of Frontal Sinus Osteomas 275

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14. Rokade A, Sama A. Update on management of frontal sinus osteo-
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4. Savić DL, Djerić DR. Indications for the surgical treatment of oste-
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Rhinology. 2001;39(2):66–70.
19. Karunaratne YG, Gunaratne DA, Floros P, Wong EH, Singh

7. Castelnuovo P, Giovannetti F, Bignami M, Ungari C, Iannetti
NP.  Frontal sinus osteoma: from direct excision to endoscopic
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 Treatment of Frontal Sinus Inverted
Papilloma 27
Luis Macias-Valle

27.1 Introduction 27.2.1 Preoperative Imaging

Sinonasal IP involving the frontal sinus is relatively uncom- Preoperative computed tomography of the paranasal sinuses
mon, accounting for less than 10% of all papillomas [1, 2]. allows better visualization of the complex anatomy and the
Histologically, inverted papilloma is considered to be a potential involvement of the frontal sinus. The radiographic
locally aggressive benign tumor with a high potential of findings in inverted papilloma focus on disease extension,
recurrence. A recent systematic review showed that the over- intrasinus highly attenuated regions, expansion, thinning or
all recurrence rate of frontal inverted papillomas is 22.4%, erosion of bone, and involvement of surrounding structures.
which is relatively high compared to inverted papillomas CT evidence of osteitic changes and hyperostosis are excel-
affecting the maxillary and ethmoid sinuses [2–4]. This is lent indicators of the site of attachment and origin of IP, with
attributable to the technical difficulties associated with oper- a positive predictive value of 100% [4–7] (Fig.  27.1). The
ating in and around the frontal sinus and proximity to the identification of hyperostosis is possible in 95% of cases.
neighboring critical structures. Retained sinus secretions and sites of possible malignant
IP of the frontal sinus can extend forward by eroding the transformation are better identified and distinguished from
anterior table of the frontal sinus. Posteriorly, it can involve the IP itself using MRI [8]. It also defines certain character-
the anterior cranial fossa and cause dural extension and fron- istics of the tumor, its origin, and its relationships with criti-
tal lobe compromise. Orbital extension is caused by the cal structures. Despite the accuracy of MRI, it lacks the
downward growth of the tumor, which can lead to diplopia, sensitivity for the assessment of the mucosal status and the
exophthalmos, and decreased vision. The mass itself can extent of affection of mucosa in certain areas, particularly if
obstruct the drainage of the frontal sinus and subsequently the IP involves and/or fills the sinus cavity.
cause frontal sinusitis.

27.3 Pearls and Potential Pitfalls

27.2 Preoperative Tips: Patient Evaluation
1. Assessment of tumor extension with computed tomogra-
Endoscopic evaluation normally hinders certain difficulties phy and magnetic resonance imaging is paramount to
since inverted papilloma can be mistaken by inflamed choose the ideal surgical technique to approach IP.
mucosa. Classically, inverted papilloma is described as a 2. Posteriorly based IPs can compromise the posterior table
digitiform reddish-gray mass, which usually arises from the of the frontal sinus or the skull base, this should be
lateral nasal wall. Preoperative biopsies are recommended to assessed preoperatively in order to prevent inadvertent
establish definitive diagnosis and to rule out dysplasia or a cerebrospinal fluid leaks during resection.
synchronous invasive squamous cell carcinoma. Endoscopic 3. Far lateral insertion of IP and/or significant invasion of
examination is normally insufficient to determine if the soft tissue (orbit, skin, etc.) might benefit from combined
lesion involves the frontal sinus pathway or the frontal sinus approaches (open and endoscopic).
proper. 4. Failure to identify and address the site of origin of the IP
will increase the risk of recurrence.

L. Macias-Valle (*)
Department of Otolaryngology, Head and Neck Surgery, Hospital
Español de México, Universidad La Salle, México City, México

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 277
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_27
278 L. Macias-Valle

Fig. 27.1  Coronal and sagittal projections of a bone window computed tomography. Recurrent inverted papilloma is observed in the right frontal
sinus. Potential site of origin for the tumor is seen at the posterior table of the frontal sinus with hyperostosis (asterisk)

Table 27.1  Classification of frontal inverted papillomas

Group Location of tumor origin
F1 Tumor origins all outside frontal sinus, tumor prolapsed into frontal sinus
F2 Tumor with part or all of the origin from the frontal sinus walls or its opening, medial to the plane of lamina papyracea
F3 Tumor with part or all of the origin from the frontal sinus walls lateral to the plane of lamina papyracea
F4 Tumor involving both frontal sinuses (origin inside or outside the frontal sinus)
F5 Tumor with extrasinonasal involvement (origin inside or outside the frontal sinus)

27.4 Step-by-Step Surgical Procedure ing a low recurrence rate (10%) with adequate tumor access
and removal. F3 and F4 tumors had higher recurrence rates
27.4.1 Classification and Surgical and outflow tract obstruction when techniques like Draf IIA
Procedure were tried as an initial approach [12–15]. Extended endo-
scopic approaches like modified endoscopic Lothrop proce-
Adequate preoperative evaluation of extension and site of dure (MELP) seem to be favored in such cases. Recent
origin of IP is crucial to establish any surgical strategy [9– publications also suggest that using mucosal covering of
11]. With a myriad of surgical techniques to approach the exposed bone produced during MELP via mucosal grafts or
frontal sinus, evidence to determine the ideal procedure for pedicled flaps reduces the chance of postoperative frontal
each patient is scarce. Most staging systems group all frontal stenosis and mucocele formation [16]. For F5 tumors and
sinus IPs into one category, causing evidence-based recom- those with significant lateral extension, open approaches
mendations regarding surgery complicated to report. A should be considered [17].
recent publication by Sham et al. attempted to provide guide-
lines for surgery selection. Tumors are classified into five
categories according to the location of pedicle, identified 27.4.2 Surgical Key Steps
intraoperatively (Table 27.1).
The authors of the study reported that 73% of their cohort 1. Adequate exposure to the frontal sinus to approach an
of F1 patients had a Draf I procedure done and the rest inverted papilloma requires a wide maxillary antrostomy
required a Draf IIA. A low rate of recurrence of less than 3% and complete ethmoidectomy.
suggests that Draf I or II should be adequate. For F2 tumors, 2. The extension of frontal sinusotomy needed can be
80% patients were treated with Draf II procedures, produc- assessed by classifications available in the literature.
27  Treatment of Frontal Sinus Inverted Papilloma 279

3. Pedicle-oriented surgery is the mainstay surgical strat- References

egy for IP.  This results in a reduced rate of recurrence
and improved long-term control of the disease. 1. Lombardi D, Tomenzoli D, Buttà L, et  al. Limitations and com-
plications of endoscopic surgery for treatment for sinonasal
Endoscopic debulking should always be done having as inverted papilloma: a reassessment after 212 cases. Head Neck.
an objective the identification of the origin site of the 2011;33:1154–61.
tumor [18, 19]. 2. Lawson W, Patel ZM.  The evolution of management for inverted
4. The site of frontal sinus attachment of the IP is decisive papilloma: an analysis of 200 cases. Otolaryngol Head Neck Surg.
2009;140:330–3.
for the extent of the endoscopic resection. 3. Sham CL, Woo JK, van Hasselt CA, Tong MC. Treatment results
5. Removal of mucosa, extensive drilling of the underlying of sinonasal inverted papilloma: an 18-year study. Am J Rhinol
bone, and cautery have been described as options to avoid Allergy. 2009;23:203–11.
recurrence of IP. 4. Kim DY, Hong SL, Lee CH, et  al. Inverted papilloma of the
nasal cavity and paranasal sinuses: a Korean multicenter study.
6. Preservation of healthy surrounding mucosa of the frontal Laryngoscope. 2012;122:487–94.
ostium is crucial to maintaining frontal neo-ostium 5. Walgama E, Ahn C, Batra PS.  Surgical management of fron-
patency. tal sinus inverted papilloma: a systematic review. Laryngoscope.
2012;122:1205–9.
6. Krouse JH.  Development of a staging system for inverted papil-
loma. Laryngoscope. 2000;110:965–8.
27.5 Postoperative Tips 7. Chiu AG, Jackman AH, Antunes MB, et  al. Radiographic and
histologic analysis of the bone underlying inverted papillomas.
1. Like any other surgery approaching the frontal sinus, Laryngoscope. 2006;116:1617–20.
8. Cannady SB, Batra PS, Sautter NB, et al. New staging system for
endoscopic debridement is important as it allows a con- sinonasal inverted papilloma in the endoscopic era. Laryngoscope.
trolled healing of the frontal ostium. Because the tech- 2007;117:1283–7.
niques used to address tumor pedicle during surgery 9. Zhang L, Han D, Wang C, et  al. Endoscopic management of the
might result in increased crust and fibrin production, inverted papilloma with attachment to the frontal sinus drainage
pathway. Acta Otolaryngol. 2008;128:561–8.
postoperative in-office debridement is crucial. 10. Yoon BN, Batra PS, Citardi MJ, Roh HJ.  Frontal sinus inverted
2. As in inflammatory pathology, patients benefit from high papilloma: surgical strategy based on the site of attachment. Am J
volume saline irrigations to promote sinonasal healing. Rhinol Allergy. 2009;23:337–41.
The addition of topical steroids will also decrease sinona- 11. Kamel RH, Abdel Fattah AF, Awad AG.  Origin oriented man-
agement of inverted papilloma of the frontal sinus. Rhinology.
sal inflammation resulting from the surgical procedure 2012;50:262–8.
itself. 12. Pagella F, Pusateri A, Giourgos G, et al. Evolution in the treatment
3. In most cases, the quality of the mucosa is good; there- of sinonasal inverted papilloma: pedicle-oriented endoscopic sur-
fore, the risk of stenosis is low provided a proper tech- gery. Am J Rhinol Allergy. 2014;28:75–81.
13. Adriaensen GF, van der Hout MW, Reinartz SM. Endoscopic treat-
nique is used. ment of inverted papilloma attached in the frontal sinus/recess.
Rhinology. 2015;53:317–24.
14. Peng R, Huang Q, Liang N, et al. A study on the prognosis of Draf
27.6 Conclusions II b surgery in treating fontal sinus inverted papilloma. Lin Chung
Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2015;29:1423–7.
15. Verillaud B, Le Clerc N, Blancal JP, et al. Mucocele formation after
IP of the frontal sinus will continue to be a challenging surgical treatment of inverted papilloma of the frontal sinus drain-
pathology for all sinus surgeons. Ideal surgical management age pathway. Am J Rhinol Allergy. 2016;30:181–4.
of frontal sinus IP should always target three different points: 16. Hildenbrand T, Wormald PJ, Weber RK. Endoscopic frontal sinus
drainage Draf type III with mucosal transplants. Am J Rhinol
pedicle identification and management, complete surgical Allergy. 2012;26:148–51.
excision of the affected mucosa, and wide postoperative 17. Albathi M, Ramanathan M Jr, Lane AP, Boahene KD. Combined
frontal drainage pathway. Several factors should be taken endonasal and eyelid approach for management of extensive frontal
into consideration for surgical planning, especially tumor sinus inverting papilloma. Laryngoscope. 2018;128:3–9.
18. Nygren A, Kiss K, von Buchwald C, Bilde A. Rate of recurrence
size, extension, and origin. The rhinologist tackling this and malignant transformation in 88 cases with inverted papilloma
pathology should be proficient in different surgical tech- between 1998–2008. Acta Otolaryngol. 2016;136:333–6.
niques, both endoscopic and open. 19. Healy DY Jr, Chhabra N, Metson R, et  al. Surgical risk fac-

tors for recurrence of inverted papilloma. Laryngoscope.
2016;126:796–801.
 Mucosal Flaps in Frontal Sinus Surgery
28
Juan Carlos Ceballos Cantu, Cristóbal Langdon,
and Isam Alobid

28.1 Introduction This can be explained because osteitic bone acts as an

inflammatory center, initiating edema and hypertrophy of the
The efficacy of the Draf III procedure is clear, but even so, a adjacent mucosa, thus narrowing the frontal recess, so when-
notable rate of restenosis and revision surgery remains. After ever grafts can be performed and the tumoral margins allow
creating a large area of bare bone left to heal spontaneously, it, grafting is recommended [9].
complications come along. Exposed bone may lead to oste-
itis acting as a source of inflammation causing mucosal
edema, hypertrophy, scarring, stenosis, and ultimately, surgi- 28.2 Indications
cal failure. Some studies report a restenosis rate of 17% dur-
ing the first year with a complete closure in 4% [1], while Grafts are highly recommended in every Draf III
other report restenosis up to 18 months after surgery [2]. approach when possible:
More specifically, an average of 33% ostium size reduc- • Chronic rhinosinusitis with or without nasal polyposis.
tion compared to its original size right after surgery has been • Transcribiform approach.
reported by some authors [3], while others have reported up • Benign tumoral pathology.
to 50–60% size reduction [4]. Complete closure occurs
between 3.9 and 19% and revision rates for the Draf III pro-
cedure are between 9 and 14%. Restenosis of the frontal neo-­ 28.3 Preoperative Tips
ostium is the most significant cause of surgical failure in
frontal sinus surgery [5]. Cotton pledget packing with nasal decongestants can be
Different attempts have been made to identify predictive placed on the roof of the nose before starting surgery, in
factors for neofrontal ostium restenosis after Draf III.  A order to have more space to work and less bleeding. It is
large intraoperative neo-ostium reduces the risk of resteno- important to start with the posterior incisions followed by the
sis; one study reported that the probability of avoiding reste- anterior ones; this will prevent blood from obstructing the
nosis after 1  year was 76% and 100% with a neo-ostium surgical field while elevating the flaps. Sometimes, infiltra-
> 300 mm2 and > 394 mm2, respectively. The average intra- tion, preferably with saline or anesthetic/vasoconstrictor can
operative neo-­ostium area is approximately 290 mm2 (50– help to dissect the mucosa. When space is reduced, this must
468  mm2) [3], and it is not always possible to obtain a be avoided because it will make it even narrower.
neo-ostium of the size referred to above, and therefore,
other techniques should be attempted. Mucosal grafting
plays an important role, the only randomized control trial 28.4 Pearls and Potential Pitfalls
comparing frontal sinus drill-­out grafts versus no recon-
struction reported significantly bigger frontal neo-ostia Mucosal flaps (pedicled and/or free) should be harvested or
1  year after surgery in patients with mucosal grafts [1]. dissected from the septum and lateral nasal wall on both the
Numerous publications indicate that the use of free or pedi- sides before drilling.
cled grafts has led to better outcomes [6–8]. The septal free mucosal flap is obtained from the same
area in which the septal window will be created, this way we
J. C. C. Cantu · C. Langdon · I. Alobid (*) minimize the donor site morbidity.
Rhinology and Skull Base Unit, ENT Department, Hospital Clinic, The mucosa above the middle turbinate and the agger nasi
Barcelona University, Barcelona, Spain
cell can be removed, for example, with the microdebrider.
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 281
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_28
282 J. C. C. Cantu et al.

However, it is best if this mucosa is raised and maintained as • Inferior: At least below the axilla of the middle turbinate,
an anterior-based pedicle graft or cut and reserved, so that in the optimum limits are recognized when an instrument
both the cases, it can be used later to cover bare bone at the can be passed across the window and used under the axilla
end of surgery. of the opposite side.
Management and positioning of flaps are important in • Posterior: The reference used as a limit is the head of the
order to prevent them from being damaged with the burr or middle turbinate.
obstructing the view during surgery. Pedicled flaps must be • Anterior: The anterior boundary of the window is initially
mobilized past the septal window and the ends of the flaps estimated. Once the window is created, if necessary, it can
should be secured, this prevents the mobilized flaps from be brought forward up to 1 cm of the frontal process of the
obstructing the view of the dissection during the drill out. maxilla.
When free mucosal grafts are brought back to the nose, • Superior: The roof of the nose.
they should be positioned under the pedicled grafts and in a
lateral fashion, usually over exposed skin as they seem to These free mucosal grafts are either dissected above the
attach better than over bone. periosteum/perichondrium or, if periosteum is included,
It is not necessary to secure the replaced flap as it adheres should be thinned as much as possible by removing the peri-
very well to the bone and skin and does not move despite osteum before repositioning to cover the bone. This is
nasal douches that can be started the next day. because the take rate of the graft is better if the periosteum/
Free mucosal grafts should be thin (without perichon- perichondrium is not included as part of the graft.
drium) or thinned if necessary, this allows better adherence. In the setting of unsuitable septal mucosa due to either a
prior Draf III or the presence of malignancy, mucosa from
the nasal floor (Fig. 28.1) or from the posterior third of the
28.5 Step-by-Step Surgical Procedure inferior turbinate can also be used as a free graft. It is impor-
tant to mark the orientation of mucociliary flow so that it can
Grafts used for frontal neo-ostium mucosal reconstruction be correctly placed at the end of surgery.
may be free or pedicled.

28.5.2 Pedicled Flaps

28.5.1 Free Grafts
Depending on the location of the flap base, these grafts cover
The first step is to harvest them from the septal mucosa on different areas of the frontal neo-ostium, although the bone is
both sides, in the region where the septal window will be cre- never covered completely.
ated (Fig.  28.1). The landmarks for the septal window are
[10, 11]: 1. In the anteriorly based septal flap technique [11, 12], the
septal flap is harvested from the more concave side of the
nasal septum. The pedicle of the flap is in the nasal sep-
tum (anterior ethmoidal artery area) with the tip of the
flap extending antero-inferiorly. After completing the
drill-out, the flap is placed over the posterior wall of the
frontal neo-ostium (Fig. 28.2).
2. The septoturbinal mucosal flap [13] is a posteriorly based
pedicled flap, also supplied by the anterior ethmoidal
artery. An inverted U incision is made from the anterior
border of the middle turbinate through the axilla of the
Septal graft turbinate to the septum. At the end of the surgery, the flap
is placed over the posteromedial frontal neo-ostium
Septum (Fig. 28.3).
3. The anterior pedicled flap [1] is a septal flap used to cover
the resected nasofrontal beak region. It is harvested after
creating the septal window. Two parallel vertical inci-
sions are made: one posterior starting high in the lateral
Nasal floor
graft nasal wall at the level of the axilla of the middle turbinate
and the second one 15–20  mm anteriorly both directed
medially to the septal mucosa until they reach the edge of
Fig. 28.1  Free mucosal grafts
28  Mucosal Flaps in Frontal Sinus Surgery 283

a b

Septum Septum

Fig. 28.2  Anteriorly based septal flap. (a) Flap incision. (b) Final flap positioning. Depending on the dimensions, it may cover posterolateral
aspect of the neo-ostium

Septum
LNW
MM

Septum MT

Fig. 28.4  Anterior pedicled flap. Endoscopic view of a right nasal

MT fossa. LNW lateral nasal wall, MM middle meatus, MT middle turbi-
nate. The dotted line represents the incisions to be made

over the agger nasi and 10–15 mm anteriorly. A h­ orizontal

incision is then made to create the tip of the flap inferiorly
Fig. 28.3  Septoturbinal mucosal flap. Endoscopic view of a right nasal just over the head of the inferior turbinate, carefully, the
fossa. LNW lateral nasal wall, MM middle meatus, MT middle
flap is elevated. At the end of the surgery, the flap is
turbinate
placed over the anterior frontal neo-ostium (Fig. 28.5).

the septal window. Finally, they are connected at the nasal At the end of the surgical procedure to achieve circumfer-
septum. Careful subperiosteal dissection is carried out, ential re-epithelialization of the frontal neo-ostium, a combi-
and the anterior pedicled flap is mobilized downwards for nation of grafts, such as bilateral anterior pedicled flaps and
protection (Fig. 28.4). free mucosal grafts, can be used so that there are minimal

4. Finally, the superior lateral anterior pedicle flap [7], gaps of exposed bone. These grafts adhere to bare bone spon-
which is also used to cover the exposed bone of the taneously and remain stable in position, with no need for
resected frontal beak consists of vertical incisions made fixation.
284 J. C. C. Cantu et al.

a b

ST ST

MT MT

IT IT

Fig. 28.5  Superolateral anterior pedicle flap on a sagittal view of right lateral nasal wall. (a) Flap incision. (b) Final flap positioning. IT inferior
turbinate, MT middle turbinate, ST superior turbinate

Sometimes, silastic frontal sinus stents are placed to pro- 3. Tran KN, Beule AG, Singal D, Wormald PJ. Frontal ostium resteno-
sis after the endoscopic modified Lothrop procedure. Laryngoscope.
vide support for the mucosal grafts and are usually removed 2007;117(8):1457–62.
on the first visit 8–13 days postoperatively [14]. 4. Casiano RR, Livingston JA.  Endoscopic Lothrop procedure: the
University of Miami experience. Am J Rhinol. 1998;12(5):335–9.
5. Anderson P, Sindwani R.  Safety and efficacy of the endoscopic
modified Lothrop procedure: a systematic review and meta-­
28.6 Postoperative Tips analysis. Laryngoscope. 2009;119(9):1828–33.
6. Illing EA, Cho DY, Riley KO, Woodworth BA.  Draf III muco-
Normal saline douches can be started as soon as the nasal sal graft technique: long-term results. Int Forum Allergy Rhinol.
packing is removed (2–5 days), and in the experience of the 2016;6(5):514–7.
7. Omura K, Nomura K, Aoki S, Katori Y, Tanaka Y, Otori N. Lacrimal
authors, there is no graft displacement. Mainly free mucosal sac exposure and a superior lateral anterior pedicle flap to improve
grafts but sometimes pedicled grafts suffer necrosis and must outcomes of Draf type II and III procedures. Int Forum Allergy
be removed; they should be maintained as long as possible to Rhinol. 2018;8:955–8.
allow maximal epithelization. Careful in-office debridement 8. Hildenbrand T, Wormald PJ, Weber RK. Endoscopic frontal sinus
drainage Draf type III with mucosal transplants. Am J Rhinol
is highly recommended since the first visit. Allergy. 2012;26(2):148–51.
Mucosal grafting provides promising outcomes, and the 9. Conger BT, Riley K, Woodworth BA. The draf III mucosal graft-
authors recommend always considering them as a routine ing technique: a prospective study. Otolaryngol Head Neck Surg
part of the surgical algorithm for frontal sinus pathology. (United States). 2012;146(4):664–8.
10. Wormald PJ. Salvage frontal sinus surgery: the endoscopic modi-
fied Lothrop procedure. Laryngoscope. 2003;113(2):276–83.
11. Yin T, Douglas R. The use of grafts in frontal sinus drill-outs. Curr
Opin Otolaryngol Head Neck Surg. 2021;29(1):31–5.
References 12. Seyedhadi S, Mojtaba MA, Shahin B, Hoseinali K.  The Draf III
septal flap technique: a preliminary report. Am J Otolaryngol Head
1. Wang YP, Shen PH, Hsieh LC, Wormald PJ. Free mucosal grafts Neck Med Surg. 2013;34(5):399–402.
and anterior pedicled flaps to prevent ostium restenosis after endo- 13. Fiorini FR, Nogueira C, Verillaud B, Sama A, Herman P. Value of
scopic modified Lothrop (frontal drillout) procedure: a randomized, septoturbinal flap in the frontal sinus drill-out type IIb according to
controlled study. Int Forum Allergy Rhinol. 2019;9(11):1387–94. draf. Laryngoscope. 2016;126(11):2428–32.
2. Schlosser RJ, Zachmann G, Harrison S, Gross CW.  The endo- 14. Khan MA, Alshareef WA, Marglani OA, Herzallah IR.  Outcome
scopic modified Lothrop: long-term follow-up on 44 patients. Am J and complications of frontal sinus stenting: a case presentation and
Rhinol. 2002;16(2):103–8. literature review. Case Rep Otolaryngol. 2020;2020:1–4.
 Part III
Complications, Postoperative
Management, and Open Issues
 Complications of Frontal Sinus Surgery
29
Stephen Ball and Richard Douglas

29.1 Introduction topical and systemic corticosteroids, and antibiotics. The

specifics of composition, dosage, and duration of trials of
Achieving long-term patency of the frontal sinus ostia medical therapy remain matters for debate, as does consen-
remains challenging. This difficulty reflects the anatomical sus on what constitutes an inadequate response.
position of the frontal sinuses, which are superior to a direct A detailed description of the indications for frontal sinus
line of vision, and so necessitates the use of angled endo- surgery falls outside the scope of this chapter. Patients with
scopes and instruments. The anatomy of the frontal sinuses mucosal thickening of the frontal sinus or its outflow tracts
shows that much variation between individuals and the should be considered for frontal sinus surgery.
drainage pathways are often hard to visualize and dissect.
When surgically cleared of the encroaching cells and septa-
tions, the frontal sinus ostia are usually smaller than the 29.2.1 Preoperative Optimization
operated maxillary and sphenoid ostomies. The frontal sinus
cannot be exenterated with the relative ease that the ethmoid The potential for complications occurring during frontal
sinuses can. Once patency has been achieved, the access of sinus dissection can be reduced by careful preoperative
lavage solution and topical medications is less to the frontal assessment of the patient. The presence of poorly controlled
sinuses than to the other sinuses. These factors conspire hypertension, coagulopathy and obstructive sleep apnoea,
against the maintenance of patency as scarring, neo-osteo- and the taking of anti-coagulant medications (both pre-
genesis, or recurrent mucosal inflammation is relatively scribed and over the counter) need to be addressed in the
easier to induce and harder to prevent. Accordingly, recur- outpatient clinic well before the day of surgery.
rent frontal sinusitis remains a common cause for revision The prescribing of preoperative corticosteroids to reduce
sinus surgery. sinus mucosal vascularity and oedema can improve the intra-
This chapter will discuss the avoidance and management operative field and reduce the possibility of complications
of frontal sinus surgery complications in chronological order, arising. There is level one evidence supporting the benefit of
from the patient’s initial assessment to the subsequent intra- both preoperative topical and systemic corticosteroids [1, 2].
operative treatment and peri-operative care. Additionally, corticosteroids are thought to be synergistic
with intraoperative local anaesthetic agents, enhancing
α1-receptor-mediated vasoconstriction [3].
29.2 Assessment

Surgical intervention of the frontal sinus in the setting of 29.2.2 Intraoperative Optimization
chronic rhinosinusitis is generally only contemplated once
appropriate medical management has been trialled and found Intraoperative visualization is aided greatly by the adminis-
to provide inadequate relief. Typically, an appropriate trial of tration of hypotensive anaesthesia (optimally administered
medical treatment includes a combination of saline lavage, intravenously rather than via inhalational) [4]. Reverse
Trendelenburg positioning and the pre-procedure placement
S. Ball (*) · R. Douglas of neuro-patties soaked with vasoconstrictor are both very
Department of Surgery, The University of Auckland, helpful in reducing mucosal bleeding. Modern high defini-
Auckland, New Zealand tion and 4K video-endoscopes have greatly improved the
e-mail: [email protected];
visualization of the frontal recess. Angled endoscopes (and
[email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 287
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_29
288 S. Ball and R. Douglas

particularly 45° and 70°) enable a much better view of the a standard sinusotomy approach (Draf IIa) but rather by a
frontal sinus ostium, facilitating safe dissection. frontal sinus drill-out procedure (Draf III) (Fig. 29.1).
Mastering the surgical techniques takes time, and frontal A range of instruments have been specifically designed to
sinus surgery should generally be provided in centres with a assist with frontal sinus dissection. Angled (or malleable)
high volume and experience in endoscopic techniques. suction tips, curettes, mushroom punches and microdebrider
National databases and case series suggest the first hundred blades greatly facilitate frontal procedures. CT navigation
procedures for solo surgeons carry higher complication rates can be a very helpful tool to verify anatomy, especially in
[5]. However, when frontal procedures are performed in a complex or revision cases in which anatomical landmarks
training setting under the supervision of an experienced ESS may not be easily recognizable. Similarly, endoscope wash-
surgeon, there is no increased rate of complications [5, 6]. ing devices are efficient adjuncts, both shortening the proce-
When a case moves beyond the comfort and competence of dure time by efficiently cleaning the lens and providing some
a junior surgeon, referring to a more experienced colleague irrigation distal to the endoscope view.
(or ideally performing the procedure as a joint case) may
help ensure achieving a good outcome. It may be better for
the frontal sinus not to be operated on at all than to have 29.3 Intraoperative Complications
longstanding obstruction or stenosis result from an inade-
quate clearance. The most common minor intraoperative complications of
Radiological identification of the frontal sinus drainage frontal sinus surgery are haemorrhage, mucosal injury and
pathway is essential in every case in which frontal sinus dis- the incomplete removal of septations or cells. Major compli-
section is performed. Frontal sinus anatomy varies greatly cations include skull base injury and orbital injury.
between patients and even between opposite sides of the
same patient. A careful review of the sinus CT scan (includ-
ing bone-windowed 1-mm slices in coronal, sagittal and 29.3.1 Haemorrhage
axial planes) will enable a mental reconstruction of the path-
way in space. There are several approaches to help imaging The greatest risk for significant haemorrhage when operating
assessment, such as the construction of building blocks [7, around the frontal sinus is presented by the anterior ethmoidal
8]. A basic understanding of sinus embryology and the devel- artery (AEA). This artery generally runs through the fovea
opment of septations from their respective ethmoturbinals ethmoidalis at or close to the attachment of the ground lamella
can greatly simplify scan interpretation (the uncinate is to the fovea (Fig. 29.2). Sometimes the fovea is pushed supe-
derived from the first ethmoturbinal and the bulla from the riorly by exuberant sinus pneumatization, leaving the artery
second and the drainage pathway always lies between these enveloped in a mesentery and consequently more vulnerable
two structures). to injury during surgery. The key anatomical point to appreci-
A review of the CT scan allows for an operative plan to be ate when operating around the AEA is that it is associated
formulated. It is better to recognize potential difficulties, with the ground lamella and accordingly is always posterior
such as high supra-frontal cells, well before the operation is to the bulla. It is found a little more posteriorly on the fovea
started as anatomical variants may be better addressed not by ethmoidalis than is sometimes realized.

Fig. 29.1  Isolated right frontal sinusitis, likely predisposed to by a prominent frontal beak (blue arrows). Such a narrow frontal sinus would be
optimally opened by a Draf 3 procedure in which the frontal beak is drilled away
29  Complications of Frontal Sinus Surgery 289

Fig. 29.3  Coronal CT image demonstrating the variable position of

the anterior ethmoidal artery. The left side sits close to the skull base.
On the right side, the ethmoidal cells have pneumatized above it, poten-
tially exposing the artery to injury (arrow)
Fig. 29.2  An intraoperative photograph of the left frontal recess. The
anterior part of the middle turbinate has been largely removed. The
anterior ethmoidal artery can be seen running across the skull base from an ophthalmologist. The most important action is to
(black arrow) at the point of attachment of the ground lamella with the
decompress the orbit, either externally through a Lynch
skull base. The attachment of the bulla anterior to this point (white
arrow) incision or endonasally by removing much of the lamina
and opening the peri-orbita (the choice of approach being
determined by the surgeon’s training and experience).
The position of the AEA can easily be verified preopera- The divided end of the artery within the orbital fat is not
tively from studying the coronal CT scans. The AEA arises typically sought as dissection within the haematoma may
from the ophthalmic artery within the orbit and passes cause further injury. Performing a lateral canthotomy
between medial rectus and superior oblique muscles. Where and cantholysis is quicker and technically easier and will
it leaves the orbit to pass into the superior nasal cavity, it buy time if there is any delay in performing a definitive
pushes the surrounding lamina medially, creating a small decompression of the medial orbital wall. The small inci-
nipple (Fig.  29.3). The artery then passes anteromedially, sion created typically heals well with minimal scarring or
typically with a gentle curve that greatly assists in its endo- functional deficit.
scopic recognition, to leave the sinuses through the lateral
lamella of the cribriform plate.
The AEA can be easily divided with a curette or a micro- 29.3.2 Direct Orbital Injury
debrider. Bleeding from the artery can be controlled by the
application of neuropatties with vasoconstrictor solutions, A careful preoperative review of the sinus CT scans is the
pro-coagulant dressings such as Surgicel, or the careful best way to prevent intraoperative orbital injury. Surgeons
application of bipolar cautery. It is surprisingly easy to create examining scans preoperatively may occasionally pick up
a CSF leak with cautery applied to the artery that is close to surgically important details not reported by the radiologist.
or on the medial skull base. An example of this is shown in Fig. 29.4 where a blow-out
If the AEA has been divided close to the lamina papy- fracture was identified by reviewing the scans.
racea, it can retract into the orbit. Arterial bleeding within Orbital complications of sinus surgery are orbital haema-
the confined space of the orbit will result (usually imme- toma, extraocular muscle injury and orbital emphysema. An
diately) in proptosis and peri-orbital ecchymosis. Urgent injury that is specific to surgery of the frontal sinus involves
decompression of the orbit is required as elevated intra- the trochlea of the superior oblique. Injury to this structure
orbital pressure can cause retinal ischemia and visual can cause diplopia, particularly when looking inferiorly
loss. This highlights the importance of having both eyes (Brown’s syndrome). The trochlea attaches anteriorly to the
clearly visible during sinus surgery. If an orbital hae- superomedial orbital wall. Accordingly, it is superior and lat-
matoma occurs, it is recommended to seek urgent input eral to the frontal beak and so is unlikely to be injured during
290 S. Ball and R. Douglas

a b

Fig. 29.4 (a) Coronal CT scan showing occult right blow-out fracture orbital prolapse into the ethmoidal cavity. This could present a signifi-
(white arrow). (b) Occult right orbital blow-out fracture (black arrows). cant risk of orbital injury if not recognized preoperatively
Intraoperative picture of the lamina papyracea dehiscence and peri-­

a standard sinusotomy. However, it is possible to disrupt the tures. Rotating the patient’s head slightly towards the surgeon
trochlea when drilling the lateral aspect of the frontal beak as and extending it slightly afford an easier plane of movement
this becomes confluent with the medial orbital wall. In expe- for the endoscope and instruments.
rienced hands, the complication rates of Draf III procedures The posterior table of the frontal sinus is composed of
are similar to Draf IIa procedures [9]. relatively thick bone and so is fortunately difficult to injure.
However, the anterior extent of the lateral lamella of the crib-
riform plate is very delicate and easily fractured. This bone is
29.3.3 Revision Surgery thinnest where penetrated by the AEA. Accordingly, the dan-
ger area when operating on the frontal ostia is posteromedi-
Revision surgery carries the highest risk as landmarks are ally. This aspect of the frontal recess is close to the most
disturbed, scarring and adhesions may have formed, and anterior part of the lateral lamella of the cribriform and so
there may be existing defects in the lamina from prior sur- should always be approached with care. The specific details
gery. CT navigation can be very helpful in the context of of CSF leak and skull base repair are covered elsewhere in
revision frontal sinus surgery, often increasing the extent to this book.
which the ostium can be safely opened. Balloting the eye
remains the most reliable confirmation of the integrity of the
lamina. Dissection close to the lamina with cold steel instru- 29.3.5 Intraoperative Packing
ments rather than powered microdebriders is less likely to
result in injury [10]. Direct injury to the lamina papyracea or In order to improve the postoperative patency rates, a large
lateral rectus is more common when operating in the eth- number of intraoperative packing devices and splints have
moid sinuses rather than the frontal. been described [11]. Although each has its adherents, there
are few clear comparative studies to guide best practice.
Silastic stents have been shown to prevent scarring and
29.3.4 Skull Base Injury maintain patency [12]. Silastic stents are usually removed
around 1 week in the outpatient clinic as biofilm formation
Anatomical variations or previous trauma may make the starts early. The most sophisticated and expensive devices
patient more at risk of a skull base injury (Fig.  29.4). are drug-eluting splints for which there are some studies
Positioning the patient’s head the same way for each proce- suggesting efficacy [13, 14]. However, many dissected
dure facilitates having the same approach angle to key struc- frontal ostia remain patent without any packing or splint-
29  Complications of Frontal Sinus Surgery 291

ing. Some ostia which are narrow or in which the sur- 29.3.8 Postoperative Care
rounding mucosa was injured may achieve a higher rate of
postoperative patency if splinted. A combination of packing, medications, lavage and debride-
ment is generally utilized in the weeks postoperatively.
Studies suggest that debridement, high volume saline irriga-
29.3.6 Frontal Balloon Dilation tion, systemic and topical corticosteroids are helpful [18].
We routinely perform the first postoperative debridement at
Balloon sinuplasty was heralded as a safer alternative to 1  week and use frontal sinus suction tips (2  mm diameter
standard frontal sinus dissection. However, subsequent olive tipped J-shaped) to enable debridement of the ostium,
experience has shown that complications may occur from which is sometimes narrowed with clots or crusts.
device malfunction or due to balloons being deployed in the
wrong anatomical area. Two groups have subsequently ana-
lysed device registries for complications of balloon sinu- 29.3.9 Postoperative Complications
plasty and identified 200 adverse events over a 10-year
period, the most common being CSF leak, pneumocephalus, The goal of frontal sinus surgery is to achieve long-term
meningitis, intracranial bleed, eye swelling, orbital fracture, patency of the ostium to allow drainage of the sinus and access
extraocular muscle injury, epistaxis and device malfunction of topical lavages and medications. Re-stenosis can result from
such as ­balloon and catheter rupture or detachment [15, 16]. recurrent mucosal inflammation, scarring, and neo-osteogene-
Four periprocedural deaths were reported from balloon sis. Mucosal sparing surgical dissection to the limits permitted
sinuplasty. Stammberger and colleagues reported a trial of by local anatomy is the best way of minimizing postoperative
balloon sinuplasty that was ended prematurely due to high restenosis (Fig. 29.5). The frontal recess can be compromised
failure rates [17]. by lateralization of the middle turbinate. Efforts to maintain the
stability of the middle turbinate intraoperatively, as well as
techniques such as suturing the middle turbinate to the septum
29.3.7 External Frontal Surgery or placing packing or stents to the middle meatus, may reduce
the rate of middle turbinate lateralization.
External approaches to the frontal sinus are rarely used as When the frontal ostium or recess becomes compromised
most frontal sinus pathology can be approached transnasally after a Draf IIa procedure, a Draf III or frontal sinus drill-out
with less morbidity. Occasionally, patients require an exter- procedure can be an effective surgical solution. There is
nal procedure for lesions that are too large or too lateral to be
removed endoscopically (e.g., some very large osteomas are
more efficiently removed via an osteoplastic flap approach).
The complications of external frontal sinus procedures are
summarized in Table 29.1.

Table 29.1  Complications of external frontal sinus surgery

External frontal procedure Complications
Frontal trephination Supratrochlear nerve injury
Facial scar
Osteoplastic flap Scar (more visible if hairline
has receded)
Altered contour of frontal
region
Mucocele formation
Division temporal branch of
facial nerve
Modified lynch Scar contraction
frontoethmoidectomy Medial canthal tendon injury
Nasolacrimal duct injury
CSF leak and skull base
injury
Cranioplasty/cranialization of the Implant infection
frontal sinuses Altered contour of frontal Fig. 29.5  A right frontal recess dissection. The mucosa of the skull
region base between the bulla ethmoidalis and the anterior ethmoidal artery
Mucocele formation has been partly denuded (white arrow), increasing the risk of postopera-
tive inflammation and scarring compromising frontal ostium patency
292 S. Ball and R. Douglas

some evidence that lining the common frontal neo-ostium revision of the stenosed ostium, usually with postoperative
with pedicled flaps or free mucosal grafts may reduce the splinting, can resolve this situation in most cases.
risk of further re-stenosis [19]. Irrespective of such manoeu- If the frontal ostium becomes completely obstructed and
vres, if there is sufficient inflammation or infection in the intact frontal sinus mucosa continues to produce mucus, a
common frontal ostium following a Draf III procedure, it is mucocele can be formed. These can expand, causing lysis of
possible for the ostium to close over (Fig.  29.6). Surgical the surrounding bones and displacement of the orbital con-
tents and frontal lobe (Fig.  29.7). Occasionally, mucoceles
are complicated by infection. They are treated by establish-
ing a persistent pathway for the drainage of mucus into the
nasal cavity.

29.4 Summary

The most important factor in preventing complications of

frontal sinus surgery is developing a thorough understanding
of the preoperative anatomy by analysis of the CT imaging in
three planes. This enables a clear operative plan to be formu-
lated and potential pitfalls anticipated. Maintaining good
operative visualization with a surgical field free of bleeding,
careful positioning of the patient and handling of angled
endoscopes and instruments usually allows successful sur-
gery to be completed safely. The most common postopera-
tive complication is re-stenosis. If this is resistant to further
medical therapy, a Draf III procedure usually establishes
long-term patency.

Fig. 29.6  The common frontal ostium created by performing a Draf III
procedure in this patient with primary ciliary dyskinesia has almost
completely stenosed (black arrow). This case was complicated by post-
operative infection and subsequent scarring

Fig. 29.7  Large left-sided frontal mucocele with erosion of the posterior table of the frontal sinus and superomedial orbit (arrows)
29  Complications of Frontal Sinus Surgery 293

References 10. Han JK, Higgins TS.  Management of orbital complications in

endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg.
2010;18:32–6.
1. Ecevit MC, Erdag TK, Dogan E, et al. Effect of steroids for nasal
11. Selvarajah J, Saim AB, Bt Hj Idrus R, et al. Current and alterna-
polyposis surgery: a placebo-controlled, randomized, double-blind
tive therapies for nasal mucosa injury: a review. Int J Mol Sci.
study. Laryngoscope. 2015;125:2041–5.
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2. Albu S, Gocea A, Mitre I.  Preoperative treatment with topical

12. Amble FR, Kern EB, Neel B 3rd, et al. Nasofrontal duct reconstruc-
corticoids and bleeding during primary endoscopic sinus surgery.
tion with silicone rubber sheeting for inflammatory frontal sinus
Otolaryngol Head Neck Surg. 2010;143:573–8.
disease: analysis of 164 cases. Laryngoscope. 1996;106:809–15.
3. Swain A, Nag DS, Sahu S, et  al. Adjuvants to local anesthet-
13. O’Brien EK. Frontal sinus surgery: a systematic approach. Cham:
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14. Goshtasbi K, Abouzari M, Abiri A, et al. Efficacy of steroid-eluting
4. Lu VM, Phan K, Oh LJ. Total intravenous versus inhalational anes-
stents in management of chronic rhinosinusitis after endoscopic
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sinus surgery: updated meta-analysis. Int Forum Allergy Rhinol.
2020;130:575–83.
2019;9:1443–50.
5. Hopkins C, Browne JP, Slack R, et al. Complications of surgery for
15. Prince A, Bhattacharyya N.  An analysis of adverse event report-
nasal polyposis and chronic rhinosinusitis: the results of a national
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audit in England and Wales. Laryngoscope. 2006;116:1494–9.
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6. Hosemann W, Draf C.  Danger points, complications and medico-­
16. Hur K, Ge M, Kim J, et al. Adverse events associated with balloon
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17. Tomazic PV, Stammberger H, Braun H, et al. Feasibility of balloon
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ning software-based module. Am J Rhinol Allergy. 2018;32:526–32.
ence. Rhinology. 2013;51:120–7.
8. Wormald PJ.  Surgery of the frontal recess and frontal sinus.

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9. Patel VS, Choby G, Shih LC, et al. Equivalence in outcomes between
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 Management of Orbital and CNS
Complications of Frontal Sinusitis 30
Beatriz Arellano Rodríguez and Mayte Pinilla Urraca

Table 30.1  Chandler classification

30.1 Introduction
Classification Clinical findings
Preseptal Eyelid edema without ophthalmoplegia or vision
The frontal sinus is the one most frequently involved in the cellulitis disturbance
development of intracranial complications, both with iso- Orbital The infection progresses posterior to the orbital
lated involvement and in combination with other sinuses. cellulitis septum and the inflammation and edema is
Complications can occur in approximately 3% of frontal greater, vision should be closely monitored
Subperiosteal Accumulation of pus in the space between the
sinusitis, these being potentially fatal, so the diagnosis must
abscess periosteal and the bone. This accumulation can
be done early. Up to 40% of patients may present more than displace the orbital content, generally in an
one of these complications. inferolateral direction. It is usually accompanied
by restricted motility and visual impairment
Orbital abscess Arises from the formation of a purulent collection
in an orbital cellulitis or from the rupture of a
30.2 Orbital Complications subperiosteal abscess inside the orbit
Cavernous Considered an intracranial complication, visual
Orbital complications account for 80% of all complications sinus deficit, ophthalmoplegia, and general symptoms
derived from acute sinusitis. More frequently, they originate thrombosis with fever and headache
from infections in the ethmoid sinuses, but in many cases,
frontal sinusitis is also associated.
Orbital complications derived from frontal sinusitis can stitutes an anatomical barrier and a brake on the spread of
progress to blindness in the affected eye and threaten the life infection into the orbital interior. In this way, orbital compli-
of the patient due to intracranial complications. cations can be preseptal and postseptal.
The anatomical situation of the frontal sinus with respect Classically, orbital complications have been classified,
to the orbit favors the development of these complications. from less to greater severity, according to Chandler classifi-
The orbital roof is especially vulnerable to the possible cation [1] as shown in Table 30.1.
spread of infection from the frontal sinus by the multiple fis- Progression from one state to the next can happen very
sures through which nerves and blood vessels pass from the quickly.
frontal sinus to the orbit. There must be a very close collaboration with the ophthal-
The extension of the infection toward the orbit is pro- mologist, and an initial assessment should always be carried
duced by contiguity or by retrograde thrombophlebitis. out to determine ocular involvement and frequent monitor-
The orbital septum is the key structure in the classification ing of motility, vision, and proptosis.
and prognosis of orbital complications; it is a fibrous lamina, The radiological evaluation will always be done by CT
which acts as the anterior margin of the orbit and extends of the sinuses in axial and coronal planes (Fig. 30.1). MRI
from the orbital rim to the eyelids. The orbital septum con- should be reserved for those cases in which intracranial com-
plications are also suspected [2].

Supplementary Information The online version contains supplementary

material available at [https://doi.org/10.1007/978-­3-­030-­98128-­0_30].
30.2.1 Treatment

B. Arellano Rodríguez (*) · M. Pinilla Urraca All patients should receive broad-spectrum antibiotics,
Otolaryngology Department, Hospital Puerta de Hierro,
which empirically cover the germs most frequently involved
Majadahonda, Madrid, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 295
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_30
296 B. Arellano Rodríguez and M. Pinilla Urraca

in acute sinusitis, mainly S. aureus (including MRSA), S.

pneumoniae, and large-negative bacilli. If an intracranial
extension is suspected, or it originates from chronic sinusitis
or dental pathology, anaerobic germs should also be covered.
Patients with exclusive preseptal involvement can be
observed for up to 24–48 h. If there is a progression of symp-
toms or absence of improvement within 48 h, surgical treat-
ment will be carried out (Fig. 30.2).
On rare occasions, preseptal cellulitis can produce an eye-
lid abscess (Fig. 30.3), which requires surgical drainage.
Although most preseptal cellulitis progress favorably
with antibiotic treatment alone, a large part of postseptal
conditions will require surgical treatment.
Surgery is needed if there is an abscess (seen in CT),
visual loss, ophthalmoplegia, or proptosis (Fig.  30.4) pro-

Fig. 30.3  Large left intrapalpebral abscess

Fig. 30.1  Left superior subperiosteal abscess Fig. 30.4  Same patient’s Fig. 30.1, note proptosis in left eye

Fig. 30.2 Treatment
algorithm in orbital Orbital
complications complication

iv antibiotic ENT Surgery

therapy (FESS)
Only if…
Visual
impairment
Oftalmoplegia
Preseptal Early
celulitis response No improvement
within 48 hours
Subperiosteal
abscess less
than 10 mm in
children
30  Management of Orbital and CNS Complications of Frontal Sinusitis 297

gression of symptoms, or failure to improve within the first Most complicated sinusitis occurs in adolescents and young
48 h of treatment [3]. men, as the frontal sinus continues to develop and vascularity
A subperiosteal abscess is the most common cause of sur- of diploic veins is maximum in that period [7].
gical treatment. However, this complication in children can The typical presentation of CNS complications of fron-
be treated conservatively if the abscess is less than 10 mm in tal sinusitis is characterized by acute or progressive severe
diameter, without impaired vision [4]. headache and persistent high fever [6]. Nasal symptoms such
as nasal congestion and rhinorrhea at the time of presenta-
tion are not necessary for making a diagnosis [7] although
30.2.2 Surgical Procedure patients may present localized frontal pressure or discom-
fort. In some cases, there may be osteomyelitis of the anterior
Endoscopic sinus surgery is the most widely used and is frontal sinus table, causing overlying edema of the forehead
focused on cleaning the affected frontal sinus, as well as the or even a pericranial abscess (Pott’s puffy tumor) [6]. The
orbital complication simultaneously. process may remain silent until serious neurological symp-
Surgery should begin with adequate vasoconstriction of toms and signs develop, such as meningism, focal neurologi-
the affected nostril, as well as infiltration of the lateral wall cal deficits, changes in mental status, lethargy, seizures, and
since it will be a bleeding surgery, as is common in acute coma. The primary diagnostic test to perform is high-resolu-
sinusitis. The eye involved must be kept open for continuous tion computed tomography (CT) with and without contrast.
monitoring. However, early changes in meningeal thickening and cere-
Maxillary antrostomy should be performed, followed britis may not show up on CT until the abscess develops;
by at least anterior ethmoidectomy, and will be extended therefore, magnetic resonance imaging (MRI) is preferred
to posterior depending on the orbital involvement (which is over CT as it is more sensitive to detect ­parenchymal abnor-
determined by the radiological involvement). Once the eth- malities (Fig. 30.5). If elevated intracranial pressure has been
moidectomy has been performed, it is possible that sponta- excluded in these imaging studies, lumbar puncture should
neous purulent drainage can be observed in this location. If be performed with cytological, microbiological, and labo-
so, a sample of the material should be taken for later micro- ratory analysis of cerebrospinal fluid [6]. It is important to
biological cultures. create a multidisciplinary approach (ENT, neurosurgery, and
Next, the lamina papyracea will be opened, not exces- infectious disease departments) to provide patient care.
sively wide, simply an opening that allows the pus to drain.
Unless there is an intraorbital collection, the periorbit
should not be opened. In this case, surgery must be per- 30.3.1 Treatment
formed jointly with the ophthalmologist, in some cases, an
open orbitotomy is necessary, mainly in the case of a lateral The primary treatment for these complications is antimi-
intraorbital abscess [5]. crobial, for 4–8 weeks with third-generation cephalosporins
Once the surgical procedure is finished, if possible, plac- (e.g., ceftriaxone), together with an anti-anaerobic agent
ing a nasal packing should be avoided to allow drainage and (e.g., metronidazole), and vancomycin should be added when
nasal douching. methicillin-resistant Staphylococcus aureus has been iso-
lated. The role of corticosteroids is controversial, they reduce
cerebral edema and delay the encapsulation process, but they
30.3 Central Nervous System (CNS) also reduce the penetration of antibiotics into the abscess and
Complications of Frontal Sinusitis increase both necrosis and the risk of ventricular rupture.
Therefore, corticosteroids should generally be used for a
The frontal sinus is the main source of intracranial compli- short duration only and are not recommended for the treat-
cations of sinusitis, followed by the ethmoid, sphenoid, and ment of intraparenchymal brain abscesses. The role of anti-
maxillary sinuses. Although less common since the advent coagulants in dural sinus thrombosis is controversial; it may
of antibiotics, these central nervous system (CNS) complica- be indicated in superior sagittal sinus thrombosis but not in
tions still occur and are associated with significant morbidity cavernous sinus thrombosis. Anticonvulsants may also be
and mortality if medical intervention is delayed [6]. Intra- administered because of the significant association of sei-
cranial complications include meningitis, epidural abscess, zures with intracranial complications [6].
subdural empyema, intracerebral abscess, and thrombosis of Small epidural collections and brain abscesses with a
the cavernous sinus or superior sagittal sinus. The infection diameter smaller than 2–3  cm may be managed conserva-
spreads from the frontal sinus by osteomyelitis of the poste- tively [8]. The indication for neurosurgical intervention is
rior table or through vascular communications between the either to relieve symptomatic intracranial mass effect or to
frontal sinus diploic veins and the dural venous plexus [6, 7]. provide a sample for microbiological diagnosis [8]. Ideally,
298 B. Arellano Rodríguez and M. Pinilla Urraca

a b c

d e f

*
*

Fig. 30.5 (a) Meningeal reinforcement (→); (b) epidural collection (→); (c) epidural abscess (*), subdural abscess (→); (d) epidural air fluid level
(→); left pansinusitis (*); (e) brain abscess (*); (f) cerebritis (→)

multidisciplinary management by a neurosurgeon and an in the treatment of sinusitis-related intracranial suppura-

otorhinolaryngologist is necessary, and when it is indicated, tion (Fig. 30.8a, b). Burr hole often suffices for an epidural
both the intracranial process and the sinus infection should abscess, but it has been associated with increased recurrence
be addressed at the same surgical procedure [9] and should when used to drain subdural empyema [8].
be as simple as possible (Figs. 30.6 and 30.7). This theoreti- For drainage of the frontal sinus, a trephination (by drilling)
cally prevents further seeding of the intracranial space from can be performed but more frequently preliminary treatment
the infected sinus and has been shown to decrease the inci- includes a functional endoscopic sinus surgery (FESS) by per-
dence of neurosurgical and sinus re-exploration [6]. forming the Draft techniques [9], to remove the hypertrophic
mucosa and purulent exudate from the sinuses [10] and to clear
their natural ostia, especially the frontal recess (Fig. 30.8c–e
30.3.2 Surgical Procedures and Video 30.1). Depending on the extent of lesions within
the nose and the sinuses, endoscopic ethmoidectomy and
There are also no consensus guidelines regarding the recom- sphenoidotomy can be performed [9]. In these inflammatory
mended neurosurgical technique, burr hole, or a craniotomy, conditions, the risk of intra and postoperative bleeding as well
30  Management of Orbital and CNS Complications of Frontal Sinusitis 299

Fig. 30.6  Algorithm of

medical action in subdural
empyema/epidural abscess as
a complication of frontal Subdural Empyema/Epidural
sinusitis. iv intravenous, FESS abscess
functional endoscopic surgery

Neurosurgery
iv antibiotic therapy (burr hole or
Only if… craniotomy)
ENT Surgery
(FESS)

Good Small
general collection Early response
condition

Brain
abscess

Neurosurgery
iv Antimicrobial (craniotomy/sterotactic guided
(≥6 weeks) CT)
ENT surgery (FESS)

Brain <3cm in
Isolated Proximity No
inflammation diameter Elevated Significant
microorganism to the improvement
intracranial mass effect
<2 weeks ventricule pressure after 4 weeks of
symptoms
iv antibiotics

Fig. 30.7  Algorithm of medical action in brain abscess as a complication of frontal sinusitis. iv intravenous, CT computerized tomography, FESS
functional endoscopic surgery

as synechiae formation is increased [9]. Another safe, effec- reaches the posterior table. After the bicoronal approach,
tive, and well-tolerated treatment for complicated frontal sinus a bone flap is performed, the osteitic foci are resected,
obstruction is the use of balloon sinuplasty. The benefits of and the entire sinus mucosa is removed. In the osteitis
balloon sinuplasty include achievement of long-term patency of the anterior table, the sinus is filled with muscle tis-
of the outflow tract and thereby effective clearance and irriga- sue and the nasofrontal sinus is closed. In internal table
tion of purulent secretions [8]. osteitis, the mucosa and the posterior table are removed,
Frontal sinus osteoplasty should be considered if ante- and the nasofrontal canal is obturated, performing a cra-
rior drainage techniques fail or if the osteitis extends or nialization [9].
300 B. Arellano Rodríguez and M. Pinilla Urraca

a b

c d e

Fig. 30.8 (a) Selective craniotomy; (b) wide craniotomy; (c) endo- (e) endoscopic visualization of the opening of the frontal recess at
scopic preoperatory image showing rhinorrhea in middle meatus; 6 months after surgery (Draft II)
(d) endoscopic image of the opening of the frontal recess during FESS;

References 6. Lane AP. CNS complications of frontal sinus disease. In: Kountakis

SE, Senior BA, Draf W, editors. The frontal sinus. Berlin: Springer;
2005. https://doi.org/10.1007/3-­540-­27607-­6_8.
1. Chandler JR, Langenbrunner DJ, Stevens ER.  The pathogen-

7. Vaidyanathan V, Shetty K.  Intracranial and orbital complications
esis of orbital complications in acute sinusitis. Laryngoscope.
of sinusitis: a case series and review of literature. Clin Rhinol Int J.
1970;80(9):1414–28.
2011;4(2):87–9.
2. Kolsi N, Zrig A, Chouchène H, Bouatay R, Harrathi K, Koubaa
8. Nicoli TK, Oinas M, Niemelä M, Mäkitie AA, Atula T.  Intra-
J.  Imaging of complicated frontal sinusitis. Pan Afr Med J.
cranial suppurative complications of sinusitis. Scand J Surg.
2017;26:209.
2016;105(4):254–62.
3. Manes RP, Marple BF, Batra P.  Orbital complications of frontal
9. Khamassi K, Mahfoudhi M, Ben Yahia A, Ben MN.  Manage-
sinusitis: the frontal sinus. Cham: Springer; 2016.
ment of intracranial complications of sinusitis. Open J Clin Diagn.
4. Ryan JT, Preciado DA, Bauman N, Pena M, Bose S, Zalzal GH,
2015;5:86–95.
Choi S. Management of pediatric orbital cellulitis in patients with
10. Szyfter W, Kruk-Zagajewska A, Bartochowska A, Borucki

radiographic findings of subperiosteal abscess. Otolaryngol Head
L.  Intracranial complications from sinusitis. Pol Otolaryngol.
Neck Surg. 2009;140(6):907–11.
2015;69(3):6–14.
5. Vázquez A, Baredes S, Setzen M, Eloy JA.  Overview of frontal
sinus pathology and management. Otolaryngol Clin North Am.
2016;49(4):899–910.
 Postoperative Management
31
Yvonne Chan and Alkis J. Psatis

Table 31.1  Strategies to improve postoperative healing

31.1 Introduction
Packing/spacers/stents
 With medical impregnation
Frontal sinus outflow tract stenosis is one of the most chal-  Without medical impregnation
lenging postoperative complications to deal with even for Nasal irrigation
the most skilled rhinologic surgeon. Due to anatomical and Local instrument debridement
technical difficulties in frontal sinus surgery, the reported Local drug therapy
postoperative patency rates vary in the literature. The overall Systemic drug therapy
patency rates for Draf II frontal sinusotomies after primary
surgery has been reported to be between 69 and 92% [1–6].
For Draf III patients, the reported long-term successful out-
comes vary between 70 and 95% [7, 8]. It was found that the
final size of the frontal ostium intra-operatively correlated
with the rate of stenosis postoperatively for both Draf II and
Draf III procedures [6]. Given the difficulty in maintaining
frontal ostia patency, long-term, diligent postoperative man-
agement is paramount. A number of postoperative strategies
can be employed to optimize wound healing of the sinonasal
mucosa, reduce local inflammation, and minimize symptoms
in order to improve outcome of endoscopic sinus surgery.
This chapter discusses a number of these strategies includ-
ing use of packing/spacers/stents in the wound, nasal irriga-
Fig. 31.1  Merocel in gloved finger spacer
tion, local instrument debridement, local and systemic drug
therapy (Table 31.1). The type and duration of the treatment
should be tailored to the individual patients in terms of their
underlying disease, surgery performed, patient-related fac- 31.2 Packing and Spacers (Without
tors, and the individual postoperative course. Medication Impregnation)

Middle meatus packing, spacers, or stents are used in endo-

scopic sinus surgery (ESS) to stabilize the middle turbinate,
Y. Chan (*) tamponade bleeding, and primarily prevent the formation of
Department of Otolaryngology-Head and Neck Surgery, adhesions that have been documented to occur in 10–30%
St. Michael’s Hospital, Toronto, ON, Canada of patients [9]. Adhesions can adversely affect postoperative
Department of Otolaryngology-Head and Neck Surgery, outcomes, particularly in the frontal sinus by directly stenos-
University of Toronto, Toronto, ON, Canada ing the frontal ostium as well as indirectly by reducing access
e-mail: [email protected]
of topical medications and debridement to the frontal region.
A. J. Psatis Middle meatal spacers can be broadly divided into absorb-
Department of Otolaryngology Head and Neck Surgery,
able (AS) and nonabsorbable (NAS). Non-absorbable ones
Queen Elizabeth Hospital, Adelaide, SA, Australia
include Merocel sponge, merocel sponge in a glove finger, or
Department of Surgery, Faculty of Medicine, University
silastic stent or sheet. Merocel sponge can be used by itself
of Adelaide, Adelaide, SA, Australia

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 301
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_31
302 Y. Chan and A. J. Psatis

and it is a non-absorbable packing (Fig.  31.1). Absorbable able nasal packing group for patients with CRS undergoing
spacers are those that biodegrade over time. Commercially sinus surgery. None of the studies included in the system-
available spacers in this category include Sepragel® Sinus atic review reported any serious adverse events, although
(hyaluronic acid derivative) (Genzyme, Ridgefield NJ), Hong et al. found that triamcinolone impregnated Nasopore
FloSeal® (bovine collagen-­derived gelatin matrix) (Baxter, showed transient systemic absorption with an associated
Deerfield IL), Rapid Rhino Sinu-Knit/Sinus Dressing® (car- suppressed serum cortisol, which normalized on the post-
boxy-methylated cellulose) (Athrocare, Austin TX), Mero- operative day 10 [19].
gel® (hyaluronic acid) (Medtronic ENT, Jacksonville FL), Commercially available drug-eluting stents have also
Chitogel® (Chitogel Pty ltd, Wellington, New Zealand) [10], made their way onto the market with the PROPEL® system
and Nasopore® (synthetic polyurethane foam) (Polyganics, (IntersectENT, Menlo Park, CA) (Figs. 31.2 and 31.3) and
Groningen, The Netherlands). Sinuband FP® (Bioinspire Technologies, Palo Alto, CA)
A systematic review and meta-analysis of middle
meatal spacers was conducted by Lee et  al. [11]. This
study analyzed eight RCT, heterogeneous in both design
and materials used. Although the authors did observe a
trend favoring the use of middle meatus spacers after sinus
surgery for synechiae prevention with NAS being more
effective than AS, it was not significant. A second sys-
tematic review and meta-­analysis by Wang et al. reported
similar findings in addition to demonstrating significantly
less bleeding when NAS packing was used [12]. It should
be noted, however, that the use of NAS is associated with
increased postoperative pain post surgery and for this rea-
son is not routinely utilized by many surgeons [13]. Given
the lack of conclusive evidence that packing improves
postoperative outcomes, a recent International Consensus
in Allergy and Rhinology (ICAR) (RS-ICAR-2021) docu-
ment recommends that middle meatus spacer may be used
as an option [14].

31.3 Drug-Eluting Spacers and Stents

Adequate drug delivery into the middle meatus and the Fig. 31.2 PROPEL® stent in middle meatus. (Photo courtesy of Dr.
frontal sinuses after sinus surgery remains a challenge given Greg Davis)
the limitations of the various topical delivery methods and
patient compliance [15]. Drug-eluting stents/spacers can
theoretically provide local medical therapy in addition to
maintaining middle meatal patency and providing hemo-
stasis [16]. The benefit of local medical delivery needs to
be balanced against the risk of inducing local inflammation,
given the foreign material, as well as the risk of unintended
systemic absorption [17]. A recent systematic review
assessing the efficacy of absorbable steroid-impregnated
nasal packing post sinus surgery identified eight random-
ized controlled trials that included both chronic rhinosi-
nusitis with and without polyposis patients [18]. In these
studies, various steroids were used in combination with
absorbable packing materials including NasoPore®, bioab-
sorbable gels, and bioabsorbable calcium alginate. Based
on their findings, the authors concluded that a statisti-
cally significant improvement in postoperative endoscopic Fig. 31.3 PROPEL® stent in frontal recess. (Photo courtesy of Dr.
appearance was found in the steroid-impregnated absorb- Greg Davis)
31  Postoperative Management 303

being well studied. The Propel® stent is a bioabsorbable 31.4 Frontal Sinus Stent
steroid-­releasing implant that contains 370  μg mometa-
sone furoate. Han et  al. performed a meta-analysis on Frontal sinus stents are fashioned and placed in the newly
two randomized controlled trials assessing the effects of created or widened frontal sinus ostia to help promote epi-
the Propel® stent on postoperative medical and surgical thelialization, avoid the development of fibrin deposits, and
interventions [20]. The authors found that the Propel stent reduce granulation and scar formation [22]. Indications for
significantly reduced the need for postoperative interven- frontal sinus stenting include intra-operative diameter of less
tion, oral corticosteroid use, polyposis, and adhesion for- than 5 mm, large exposed bony surface, purulence, middle
mation. A major limitation of this study was the use of turbinate lateralization, extensive polyposis, revision surgery,
a noneluting vicryl-­based stent as the control, with vicryl and previous stenosis. There is no consensus on the type of
well documented to create an inflammatory foreign body frontal sinus stent and the duration of stenting in the litera-
reaction. Furthermore, many of the authors of this paper ture. A number of different materials have been used as fron-
were paid consultants for Intersect, the manufacturers tal sinus stents ranging from drug-eluting absorbable stents
of Propel®. Sinuband FP® is a bioabsorbable fluticasone to synthetic sheeting such as silastic or more rigid stents such
propionate (FP)-eluting implant that was investigated in a as silicone or Dacron (Fig.  31.4). Most drug-­eluting stents
small randomized controlled trial for patients with chronic are short term and dissolve within weeks, whereas nonab-
rhinosinusitis with nasal polyposis undergoing endoscopic sorbable stents are usually left in longer until re-epitheliza-
sinus surgery [21]. This study compared Sinuband® with tion has occurred. Silastic sheeting can be left for a few days
and Sinuband® without steroid with Merocel as a con- to a month, whereas silicone stents have been reported to be
trol. Results demonstrated that postoperative appearance placed for a longer-term period such as months to years [23].
is better in the Sinuband FP® arm. The RS-ICAR-2021 A pooled analysis of two randomized controlled tri-
document currently recommends the use of steroid-elut- als evaluated the effects of bioabsorbable steroid-releasing
ing implants or spacers for select patients with chronic implants (mometasone furoate, 370 μg) on the frontal sinus
rhinosinusitis post sinus surgery [14]. There is certainly ostia post endoscopic sinus surgery [24]. At day 30, the
evidence that there is reduction in polyposis and adhesion analysis demonstrated that the steroid-releasing implants
formation which may translate into reduction in postopera- significantly reduced the need for oral steroids, as well as
tive interventions; however, given the high cost of these immediate postoperative interventions. At day 90, the steroid
devices, specific usage should be at the surgeon’s discre- sinus implant group required less postoperative interventions
tion taking into consideration patient factors such as those and had a reduced restenosis rate and an increased estimated
similar to the ones included in the clinical trials. Unfor- frontal sinus ostia diameter. In a subgroup analysis, these
tunately, these drug-eluting stents are not available at the effects are sustained regardless of asthma status, previous
institutions where the authors practice; hence, no practical endoscopic sinus surgery, extent of polyps, extent of surgery,
experience can be drawn. or Lund–Mackay CT score in the frontal sinus ostium.

a
b c

Fig. 31.4 (a) Silastic template for the frontal sinus; (b) the ends of the silatic are rolled up and held with a giraffe forceps; (c) silastic placed in
the frontal recess. (Photos courtesy of Dr. Luis Fernando Macías)
304 Y. Chan and A. J. Psatis

In addition to corticosteroids, doxycycline has also been et al. review suggested that the currently available evidence
used in a drug-eluting stent study assessing its effects on is not enough to make a recommendation for postoperative
frontal sinus patency postendoscopic sinus surgery [25]. In antibiotic use [26].
this study, the authors concluded that the doxycycline (DC)- Another important factor to consider in the decision to
releasing stents significantly lowered local bacterial colo- treat with antibiotics after surgery is patient comorbidities.
nization and matrix metalloproteinase-9 (MMP-9) levels, a A retrospective observational study evaluating the impact
protein implicated in poor healing. In addition, the frontal of antibiotics following reconstructive surgery found that
sinus region on the DC stent side also demonstrated signifi- tobacco use, diabetes, and immunodeficiency were factors
cantly better healing. Although steroid or antibiotic impreg- that were associated with higher infection rates [30]. In these
nated frontal sinus stents appear promising, larger studies are susceptible patient populations, it may be prudent to con-
needed. sider prescribing antibiotics, especially in patients who are
found to be actively infected at the time of surgery. The most
recent ICAR-RS-2021 review recommends antibiotics as an
31.5 Postoperative Antibiotics option for postoperative use, citing both benefits and poten-
tial side effects [14].
Postoperative use of antibiotics following sinus surgery is a
common practice among many surgeons. It is postulated that
they may aid wound healing by preventing bacterial infec- 31.6 Postoperative Systemic Steroids
tion and reduce the risk of toxic shock syndrome if pack-
ing was used. Antibiotic use is not without risk; however, Limited evidence is available in the literature about systemic
it can result in side effects including gastrointestinal symp- corticosteroid use postoperatively. One double-blind ran-
toms, clostridial difficile colitis, and anaphylaxis as well domized controlled trial evaluated the use of oral predniso-
as contribute to the development of antibiotic resistance. A lone 30 mg daily for 5 days preoperatively and then 9 days
recent meta-analysis by Swords et al. of five RCTSs and one postoperatively [31]. This study did not report any benefit in
cohort study showed significant variability in the choice of post-op symptom scores with oral corticosteroid use; how-
antibiotics, start time postoperatively as well as dosing and ever, it showed improvement in endoscopic appearances at
duration of treatment [26]. Four of the studies used a short 2  weeks postoperatively compared to the placebo group.
course (2–3  weeks) of anti-staphylococcal agents such as Brescia et al. performed a sequential nonrandomized trial in
co-­amoxiclav, quinolone, or co-trimoxazole, one study used patients with eosinophilic polyps. Using polyp recurrence as
12 weeks of low-dose macrolide therapy and the prospective the primary outcome measure, they compared the postop-
cohort study used a 2-week course of culture-directed anti- erative use of topical nasal corticosteroids alone with topical
biotics [26, 27]. In terms of symptom improvement, only the and oral corticosteroids use [32]. The patients were enrolled
study by Amali et al. that assessed the long-term use of mac- over a 2-year period and followed up for at least 36 months.
rolides showed a significant difference in SNOT-22 reduc- The authors failed to identify any difference in polyp recur-
tion, although the absolute difference between SNOT-22 rence rate or disease-free interval between the two groups at
scores of the two groups was 4.22 considered to be less than 1  year. The risks of systemic corticosteroid use postopera-
the minimal clinically important difference of 9 [28]. With tively must be weighed on an individual patient basis. Cur-
regard to objective endoscopic outcomes, only the study by rently, the RS-ICAR-2021 recommends systemic steroid use
Haxel et  al., which assessed the long-term use of erythro- as an option post sinus surgery [14].
mycin postoperatively, showed a significant improvement in
the early postoperative period [29]. However, at 6  months
post-­surgery, there was no significant difference between 31.7 Saline Irrigation
the antibiotic and placebo studies [29]. Interestingly, the
study by Amali et al., which examined an even longer use Saline irrigation is generally well tolerated and is thought
of 6 months macrolide antibiotics post-surgery, reported no to improve postoperative healing by mechanically removing
difference in the endoscopic scores at 3- or 6-month post crusts and clots secondary to surgical trauma and improv-
surgery, but did show a significant improvement in the anti- ing mucociliary function. A systematic review of the litera-
biotic group at 12 months. Based on these findings, Swords ture by Rudmik et al. of six RCTs showed that postoperative
31  Postoperative Management 305

demonstrated significant clinical improvements with stan-

dard topical steroid sprays following ESS. It was determined
that CRS with nasal polyposis patients benefited the most
in terms of decreased recurrence rate and increased time to
recurrence of polyps. In their systematic review, Pundir et al.
evaluated several studies of different topical corticosteroids,
including mometasone spray, budesonide spray, beclometha-
sone spray, and fluticasone spray [42]. Their meta-analysis
observed that although topical corticosteroids did not signifi-
cantly improve subjective symptom scores, they did improve
endoscopic appearance objectively [42]. It is possible that
use in the early postoperative setting may be less effective
due to decreased contact between the steroid and the mucosa
due to the presence of clots, debris, and absorbable pack-
ing material. It is for this reason that Weber and Hoseman
suggested starting topical steroid application after the first
debridement [43].
Since corticosteroid sprays are essentially an anterior
nasal treatment and do not reach all the paranasal sinuses,
the use of high-volume saline irrigation to deliver corticoste-
roids has become increasingly popular among ENT surgeons
in recent times. A meta-analysis by Yoon et al. specifically
Fig. 31.5  Vertex down position assessed corticosteroid high-volume irrigations in the post-
operative period [44]. Pooled data from this meta-analysis
saline resulted in significant improvements in endoscopic and demonstrated that although topical steroids resulted in a
symptom-based outcomes [15]. Another systematic review statistically significant improvement in both quality-of-life
by Chen et al. assessed the efficacy of various forms of nasal symptoms and endoscopic scores in the early postoperative
irrigation after endoscopic sinus surgery [33]. The authors period, there was no significant benefit over using saline
found no significant difference in symptom or endoscopic alone. This may be due to the masking of the steroid effects
scores between the saline group, Ringer’s lactate, hypertonic by the positive impact of saline irrigation on the mucociliary
saline, electrolyzed acid water, and Amphotericin B. clearance or the diluted dose of steroid being insufficient to
Cadaveric distribution studies have examined the effects treat the nasal mucosa.
of head position, delivery devices, and volume on frontal Importantly, no adverse effects of steroid irrigation such
sinus penetration [34, 35]. These studies suggest that post- as increased intraocular pressure or adrenal suppression were
frontal sinusotomy, a squeeze bottle volume of greater than identified. Considering the evidence in the literature overall,
100 mL in a vertex down position (Fig. 31.5) resulted in the the RS-ICAR-2021 document recommends the use of topical
best frontal sinus distribution [36], with 200  mL achiev- nasal steroids post ESS [14].
ing the best distribution. Both the EPOS 2020 and the Topical decongestant is not routinely used in the postop-
RS-ICAR-2021 documents recommend the use of saline erative period; however, given their potential to reduce muco-
irrigation in the postoperative period [14, 37]. sal edema, a randomized trial evaluated its role in the post
sinus surgery regimen. Humphreys et al. found no difference
in sinonasal symptom scores or bleeding events between
31.8 Intra-Nasal Medications topical xylometazoline and saline spray groups [45]. In fact,
the xylometazoline group reported more significant postop-
Topical delivery of medications early in the postoperative erative pain scores. The RS-ICAR-2021 review made a rec-
period has been extensively studied. Rudmik’s evidence-­ ommendation against the use of topical decongestants due
based review identified four randomized, double-blind, to their potential side effects of rhinitis medicamentosa [14].
placebo-­controlled trials that examined the roles of standard Local antibiotic therapy aims to deliver higher concentra-
topical nasal steroids sprays on post sinus surgery clinical tion of antibiotics to the active infection site while avoiding
outcomes [15, 38–41]. Three of these four level 1b studies the systemic effects of antibiotics. An evidence-based review
306 Y. Chan and A. J. Psatis

of topical antibiotics use by Rudmik et  al. concluded that Although those studies assessing differences in Sino-Nasal
the evidence does not support the use of local antibiotics Outcome Test-22 (SNOT-22) scores and endoscopic scores
by spray application or nebulizer [46]. High volume irriga- showed a trend to lower scores in sides/patients that had
tion with 0.05% mupirocin was found to induce short-term debridement performed, a statistically significant difference
improvement of the symptoms and reduction of S. aureus at was not achieved. Adhesion formation, however, was found
the end of the therapy; however, recolonization is common to be significantly lower in the debridement group, with a
[47]. Hence, further studies are required to define its role. number needed to treat of five patients to prevent adhesion
There is currently no recommendation for the use of nasal formation in a single patient. The ICAR-RS-2021 recom-
rinsing with antibiotics, but it may be considered on an indi- mends postoperative sinonasal debridement with grade B
vidual case basis guided by cultures and sensitivities [46]. evidence [14]. Most surgeons will start 1–2 weeks postoper-
atively at 2-week intervals. The protocol varies according to
surgeon preference, severity of crusting, presence of granu-
31.9 Postoperative Debridement lation tissues, degree of inflammation, position of middle
turbinate, presence of infection, and patient discomfort or
Postoperative debridement of blood clots, crusts, unresorbed tolerance [51]. Specifically, for the frontal sinus, angled
packing and adhesions is commonly practiced at various time scopes and curved instrumentation are critical in the success-
points post-surgery. It is thought that this practice is likely ful debridement of the cavities (Figs. 31.6, 31.7 and 31.8).
to reduce inflammatory load and the potential scaffold for The authors generally assess the postoperative patients
scarring [48]. In 2015, Green et al. performed a systematic 10–14 days after surgery. The preference is to aspirate and
review on postoperative nasal debridement following sinus
surgery which reported on six randomized control trials
with a pooled analysis of 337 patients [49]. Four of the six
studies demonstrated some benefits in early post-op symp-
tom scores; however, there was no significant difference at
long-term follow-up in either sinonasal outcome scores or
endoscopic scores. Patient discomfort was found to be sig-
nificantly higher in patients who underwent debridement.
A Cochrane review on this topic was also recently pub-
lished [50]. Four randomized controlled trials with 152
patients were included in this review where two of the stud-
ies used patients as their own controls (“split-nose”). Pri-
mary outcomes evaluated included health-related quality of
life (HRQoL) scores, disease severity, and adverse effects.
Secondary outcomes assessed were endoscopic appearance,
postoperative medication use, and revision surgery rate. Fig. 31.6  Up-biting and straight forceps for postoperative debride-
The duration of these studies ranged from 3 to 12 months. ment in office

Fig. 31.7  Various Giraffe

forceps for postoperative
debridement in office
31  Postoperative Management 307

remove loose debris and crusting under 0° or 30° telescope egies presented in this chapter aim to mitigate these possible
guidance, keeping in mind patient tolerance and comfort complications, especially in the frontal sinus. Table 31.2 pro-
levels. vides a summary of the RS-ICAR-2021 recommendations
for post ESS care. The use of middle meatus spacer is rec-
ommended as an option by the most recent RS-ICAR-2021
31.10 Summary while the same document recommended the use of steroid-­
eluting implants or spacers in select patients with CRS post
Postoperative failures of ESS may be caused by a number endoscopic sinus surgery [14]. No consensus has been estab-
of factors including recurrent polyposis, adhesion formation, lished for the use of frontal sinus stenting, although stenting
middle turbinate lateralization, and ostial stenosis. The strat- has been shown to help maintain ostial patency with both
nonabsorbable and absorbable drug-eluting stents. Given its
potential benefits and side effects, antibiotic use has been
recommended as an optional postoperative adjunct. Limited
evidence is available for systemic corticosteroid use, and
it is recommended as an option post sinus surgery in RS-
ICAR-2021 [14]. Saline irrigation is generally well tolerated
and has been shown to improve endoscopic and symptom-­
based outcomes post sinus surgery [15]. The use of intranasal
corticosteroids post sinus surgery has been found to improve
endoscopic appearance post surgery and reduce the risk of
recurrence of nasal polyposis [42]. Endoscopic debridement
in the postoperative period has been shown to significantly
lower the risk of adhesion formation, and the protocol will
vary according to surgeon preference, patient factors, pres-
ence of infection, and severity of crusting [51].
The authors have generally used steroid-soaked absorb-
able spacers in the middle meatus for both stenting and
its potential steroid application postoperatively. No spe-
Fig. 31.8  Curved and straight suctions cific stenting of the frontal sinus ostium is routinely per-

Table 31.2  Summary of RS-ICAR-2021 recommendations for postoperative management for CRS
Intervention Benefits Harm Policy level
Postoperative Potential reduction in adhesion and Potential increase in discomfort; rare Option
packing improvement in ostial size risk of toxic shock syndrome; potential Evidence suggesting packing
increase in adhesion formation reduces adhesion formation is
limited
Postoperative Reduction in polyposis and adhesion Potential local reaction or misplacement Option
drug-eluting which translates into reduction Corticosteroid-eluting stents can be
implants considered in the postoperative
ethmoid cavity
Oral antibiotics Improved symptoms and endoscopic GI upset, colitis, anaphylaxis, bacterial Option
appearance; reduction of crusting resistance There are benefits but also note
potential side effects
Saline irrigations Improved symptoms and endoscopic Local irritation; ear symptoms Recommendation for use of nasal
appearance; well tolerated saline irrigation
Systemic Improved endoscopic appearance; Insomnia, mood changes, Option
corticosteroids reduction in polyp recurrence hyperglycemia, gastritis, increased
intraocular pressure; avascular necrosis
Topical Improved symptoms and endoscopic Epistaxis, headache Strong recommendation for topical
corticosteroids appearance; reduction in polyp corticosteroids
recurrence rate
Topical Potential reduction of mucosal Increased pain, possible rhinitis Recommendation against topical
decongestants swelling and bleeding medicamentosa decongestants
Sinus cavity Improved symptoms and endoscopic Inconvenience, pain, epistaxis, syncope, Recommendation for postoperative
debridements appearance; reduced risk of synechia mucosal injury debridement
and turbinate lateralization
308 Y. Chan and A. J. Psatis

formed. Antibiotics are used by the authors if purulence 15. Rudmik L, Soler ZM, Orlandi RR, et al. Early postoperative care
following endoscopic sinus surgery: an evidence-based review with
is seen intra-­operatively, and it will usually be targeted to
recommendations. Int Forum Allergy Rhinol. 2011;1:417–30.
the specific microbiology sensitivity once it is available. 16.
Bednarski KA, Kuhn FA.  Stents and drug-eluting stents.
The authors’ postoperative regimen includes large volume Otolaryngol Clin North Am. 2009;42:857–66.
saline irrigation three times daily, starting day 1 postopera- 17. Valentine R, Wormald PJ. Are routine dissolvable nasal dressings
necessary following endoscopic sinus surgery? Laryngoscope.
tively until the first visit, followed by the addition of ste-
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debridement is usually carried out between days 10 and 14 impregnated nasal packing in functional endoscopic sinus surgery
and as needed during the postoperative period. Given the for chronic rhinosinusitis: a systematic review. Laryngoscope.
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heterogeneity of the CRS patient population, it is prudent
19. Hong SD, Kim JH, Dhong HJ, et  al. Systemic effects and safety
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to the specific patient needs. surgery: a randomized, double-blinded, placebo-controlled study.
Am J Rhinol Allergy. 2013;27:407–10.
20. Han JK, Marple BF, Smith TL, et  al. Effect of steroid-releasing
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31  Postoperative Management 309

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 Debates and Controversies in Frontal
Sinus Surgery 32
Mark Arnold and John M. DelGaudio

32.1 Introduction cerebrospinal fluid (CSF) leak occurred during partial mid-
dle turbinate resection [2]. In 2018, Tan et al. prospectively
Safe and efficient dissection of the frontal sinus outflow tract enrolled 177 patients, with 93 undergoing partial middle
is an essential skill for the sinus surgeon. Due to variable turbinate resection and 84 having their middle turbinates
ethmoid cell pneumatization, the frontal outflow anatomy is preserved. Patients undergoing partial middle turbinate
often both narrow and complex. With the added difficulty resection had higher Lund–Mackay scores and were more
of approaching the recess at acute angles, decision-making likely to have nasal polyps. However, with a mean follow-up
at this stage is critical for favorable postoperative outcomes. of 17.4 months, they found equivalent subjective outcomes
Consequently, diverse techniques have been described in the measurements [3].
literature. This chapter seeks to highlight and explore the In the first randomized-controlled trial to evaluate the
evidence of the most controversial topics and debates among impact of middle turbinate resection on ESS outcomes,
frontal sinus surgeons. Hudon et  al. followed a small group of 16 patients. Nasal
cavities were randomized with one side undergoing middle
turbinate resection while the contralateral middle turbinate
32.2 Management of the Middle Turbinate was preserved. While the resected side had slightly more
During Frontal Sinus Surgery crusting and better endoscopic visualization in the early
postoperative period, by 6 months there was no difference in
Traditionally, it has been felt that preservation of the middle endoscopic scores between groups [4].
turbinate is critical during functional endoscopic sinus sur- Furthermore, recent evidence has demonstrated Draf
gery. Those who argue in favor of middle turbinate preserva- IIb as a safe and effective technique, as complications are
tion feel that resection may risk hyposmia, iatrogenic frontal rare from partial anterior middle turbinate resection. Turner
sinusitis, skull base injury, and loss of the filtering effect of et al. [5] followed 22 patients for an average of 16.2 months
the middle turbinate. Furthermore, resection removes the after undergoing Draf IIb, with patency maintained in 20
turbinate as a landmark for future surgeries. However, a patients.
polypoid or floppy turbinate may lateralize, occurring in up In the authors’ experience, most primary cases will begin
to 25% of patients undergoing Draf 2A [1]. Consequently, with a Draf IIa. If necessary, to achieve a frontal sinus open-
select cases may benefit from partial middle turbinate resec- ing of at least 4 mm or larger, middle turbinate resection is
tion to maintain the patency of the frontal sinus outflow tract. performed conservatively. Anterior–medial dissection at this
A 2019 multi-institutional study by Pinther et al. followed stage is critical for a Draf IIb, as it widens the frontal sinus
91 patients with chronic rhinosinusitis with nasal polypo- outflow tract in an anteromedial direction (Fig. 32.1). Drill-
sis undergoing partial or full middle turbinate resection by ing is rarely necessary. Dissolvable packing material placed
three surgeons. Over a 7.5-month average follow-up period, lateral to the remaining middle turbinates reduces postop-
none had epistaxis requiring a return to the operating room, erative lateralization and subsequent frontal outflow obstruc-
nor had any developed frontal ostia stenosis. However, one tion.

M. Arnold · J. M. DelGaudio (*)

Department of Otolaryngology-Head and Neck Surgery,
Emory University School of Medicine, Atlanta, GA, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 311
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_32
312 M. Arnold and J. M. DelGaudio

a b

Fig. 32.1 (a) Right frontal sinus Draf IIa. (b) Right frontal sinus Draf IIb. Note widened frontal sinusotomy anteriorly and medially with the Draf
IIb. The patient had previously undergone partial middle turbinate resection

32.3 Use of Stents and Grafts During cases re-mucosalization occurs quickly, with less crusting,
Frontal Sinus Surgery scarring, and stenosis as compared to inflammatory condi-
tions. Furthermore, in certain cases such as an inverted papil-
To reduce postoperative crusting and re-stenosis, opening the loma, the area of the pedicle should remain exposed to allow
frontal sinus outflow tract is best performed with hand instru- for surveillance. In the authors’ practice, grafting is employed
mentation. By only removing the bony septations that line for all inflammatory cases that require drilling (Fig. 32.2), but
the tract, mucosa along the nasal beak, intersinus septum, not necessarily in noninflammatory cases (Fig. 32.3).
and posterior table can be preserved. However, at times this Grafting of the exposed bone reduces crusting while
is not possible. Narrow outflow tracts, thick nasal beaks, and allowing for mucosal ingrowth. After following 29 Draf III
thick bony frontal intersinus septae may halt any attempts at procedures with mucosal grafting harvested from the supe-
hand dissection. In this setting, drill-outs may be necessary rior septectomy, Conger et al. noted that all patients met the
to create an adequate opening. definition of surgical success with less than a 50% reduction
An alternative may be the so-called middle-ground dem- in anterior–posterior diameter, with an average of 11.7 mm
onstrated by Bhalla et al. [6]. In six cadavers, they performed intraoperatively to 10.8  mm post-operatively [7]. In the
Draf IIbs with a superior septectomy, sparing the nasal beak author’s experience, these grafts are easily supported with
and intersinus septum of any drilling. Next, they performed steroid-eluting stents to maintain frontal sinus patency dur-
irrigations under visualization followed by a Draf III and ing the healing process (Fig.  32.2). Free mucosal grafting
subsequent irrigation. They noted a similar volume of irriga- is most commonly performed to resurface the drilled bone
tion entering the frontal sinuses. of the frontal outflow tract. This is effective in relining the
If drilling is necessary, stenting and grafting should be bone, although this may add donor-site morbidity and opera-
considered to support healing. Certainly, the amount of drill- tive time for harvesting. Alternatively, collagen matrix grafts
ing can be reasonably minimized. While thinner portions of may also be used to cover areas of exposed bone anteri-
the frontal intersinus septum can be taken down, it is unnec- orly over the nasal beak and posteriorly along the intersi-
essary to drill a broad-based intersinus septum attachment nus septum. Although there is a cost associated with these
flush to the posterior table, as this not only increases the area grafts, there is no need to harvest native tissue, thus reducing
of exposed bone but also risks skull base injury. For many donor site morbidity and operative time. Securing the grafts,
noninflammatory pathologies, grafting and stenting can be whether mucosal or collagen matrix, is important to allow
avoided, as there is little bony inflammatory reaction. In these the grafts to take.
32  Debates and Controversies in Frontal Sinus Surgery 313

a b

Fig. 32.2  Draf III cavity after revision surgery for allergic fungal sinusitis. (a) Free mucosal grafts supported by steroid eluting stents. (b) Well-­
healed 1-year postoperative endoscopy

a b

Fig. 32.3 (a, b) Well-healed Draf III cavity 3 months after resection of frontal inverted papilloma, without grafting. Note some mild residual
granulation on the right side (a)

32.4 Extent of Frontal Sinus Surgery (AERD) have been shown to have aggressive polyp recur-
rence and in certain cases may benefit from an upfront Draf
While most frontal sinusotomies will remain patent after III [9, 10]. Yet not every case series has demonstrated benefit.
surgery, select patients may benefit from an upfront Draf In a review by Wong et al. [11] 104 patients who underwent
III. In 2013, Naidoo reviewed 339 patients who underwent a Draf III via “Outside-In” approach demonstrated decreased
frontal sinusotomy [8]. They found that there was less than SNOT-22 scores and subjective improvements in olfaction,
a 15% failure rate, necessitating a Draf III. The group that yet the subset of 13 patients with AERD had poor outcomes
failed had risk factors including asthma, extensive nasal pol- on univariate analysis. In the authors’ experience, an upfront
yposis, narrow frontal ostia less than 4  mm, and extensive Draf III is usually unnecessary except in cases with extensive
radiologic disease with a Lund–MacKay score over 16. Sim- nasal polyposis along with a very narrow (< 4 mm) frontal
ilarly, patients with aspirin-exacerbated respiratory disease sinusotomy despite an appropriate Draf IIb.
314 M. Arnold and J. M. DelGaudio

32.5 Outside-In Versus Inside-Out Draf III approach and the “Outside-In” approach. Classically, a Draf
III occurs as a stepwise summation of the previous Draf
Among the many techniques to access the frontal sinus, the frontal sinusotomies. After a Draf IIb is performed, dissec-
Draf III allows for the greatest access endoscopically and tion proceeds with a superior septectomy followed by the
has nearly replaced the need for an open osteoplastic flap. removal of the frontal intersinus septum and nasal beak.
While originally described as a salvage procedure for inflam- This ­technique moves from the “inside” starting with Draf
matory conditions, Draf III allows for expanded endonasal IIa, followed by progressive removal of mucosa and bone
approaches to the frontal sinus and anterior skull base for to expand to the limits of the Draf III cavity. Identification
other pathologies including CSF leaks, tumors, and muco- of the natural frontal sinus outflow tract is essential with
celes. the “Inside-­Out” approach, as dissection starts centrally and
The limits of a Draf III dissection include the first olfac- moves outward.
tory fila posteriorly, the lamina papyracea laterally, and ante- An “Outside-In” approach has been described as a safe
rior periosteum of the frontal bone anteriorly [12]. There and efficient alternative (Figs.  32.4 and 32.5) [13]. After
are two leading techniques to achieve this, the “Inside-Out” an anterior ethmoidectomy is performed to identify the

a b

Fig. 32.4  Endoscopic Modified Lothrop “Outside-In” approach. (a) Mucosal incision. (b) Identification of the first olfactory filament at suction
tip. (c) Anterior septectomy
32  Debates and Controversies in Frontal Sinus Surgery 315

a b

Fig. 32.5  Endoscopic modified Lothrop “Outside-In” approach. (a) Entering the frontal sinus through frontal beak. (b) Mucosal grafting of the
frontal beak. (c) 6-month postoperative endoscopy

lamina, a superior mucosal flap is elevated from the frontal There are strong proponents of each technique. Proponents
process of the maxilla to the upper septal mucosa under the of the “Outside-In” technique maintain that the landmarks
nasal bones and then elevated posteriorly to the first olfac- required for the “Inside-Out” approach are not necessary
tory neuron. A broad front of bony drilling then commences and can be often distorted in complex revision surgery. In
anteriorly through the nasal beak from orbit to orbit. Drill- addition, bony removal is felt to be more efficient and com-
ing continues until the frontal sinus is entered superiorly, plete and can be performed using a zero-degree endoscope
and this is widened. Next, posterior drilling is continued [13]. However, critics feel that the amount of drilling may be
to remove any remaining partitions to connect the frontal excessive and not tailored to the patient’s anatomy. In addi-
sinus outflow tract to the anterior ethmoids. Finally, the tion, there is a learning curve to the technique, especially
intersinus septum is also removed. Since this technique with “blind” drilling through the block of bone in the frontal
begins on the “outside,” drilling through the frontal beak beak and in identifying the first olfactory neuron, a critical
until the frontal sinus cavity is entered superiorly, and then landmark to avoid skull base injury.
connects to the natural frontal outflow tract, it is referred to In the authors’ experience, most frontal sinus surger-
as “Outside-In.” ies begin with a Draf IIa using all available landmarks, in
316 M. Arnold and J. M. DelGaudio

an inside-out approach. Once the posterior table is safely 3. Tan NC-W, Goggin R, Psaltis AJ, Wormald P-J. Partial resection of
the middle turbinate during endoscopic sinus surgery for chronic
identified bilaterally, dissection moves anterior and medial.
rhinosinusitis does not lead to an increased risk of empty nose syn-
As early as possible, binostril techniques are employed to drome: a cohort study of a tertiary practice. Int Forum Allergy Rhi-
efficiently remove bone and expand the Lothrop cavity. nol. 2018;8(8):959–63. https://doi.org/10.1002/alr.22127.
If, however, the frontal sinus outflow tract is unable to be 4. Hudon MA, Wright ED, Fortin-Pellerin E, Bussieres M. Resection
versus preservation of the middle turbinate in surgery for chronic
cannulated, an “Outside-In” approach is utilized. As there
rhinosinusitis with nasal polyposis: a randomized controlled
is no frontal sinus outflow tract to safely start dissection, it trial. J Otolaryngol Head Neck Surg. 2018;47(1):67. https://doi.
is appropriate to begin as far anterior as possible. Dissec- org/10.1186/s40463-­018-­0313-­8.
tion through the nasal beak will bring the surgeon safely 5. Turner JH, Vaezeafshar R, Hwang PH.  Indications and out-
comes for Draf IIB frontal sinus surgery. Am J Rhinol Allergy.
to the frontal sinuses, typically at the top of the nasal beak
2016;30(1):70–3. https://doi.org/10.2500/ajra.2016.30.4268.
(Fig. 32.5a). Once the posterior tables are in view, dissection 6. Bhalla V, Sykes KJ, Villwock JA, Beahm DD, McClurg SW,
can safely proceed posteriorly to avoid inadvertent injury to Chiu AG. Draf IIB with superior septectomy: finding the “middle
the skull base. ground”. Int Forum Allergy Rhinol. 2018;9(3):alr.22228. https://
doi.org/10.1002/alr.22228.
7. Conger BT, Riley K, Woodworth BA. The draf III mucosal graft-
ing technique: a prospective study. Otolaryngol Head Neck Surg.
32.6 Conclusion 2012;146(4):664–8. https://doi.org/10.1177/0194599811432423.
8. Naidoo Y, Bassiouni A, Keen M, Wormald PJ. Risk factors and out-
comes for primary, revision, and modified Lothrop (Draf III) frontal
Given the variable anatomy, pathologies, and techniques,
sinus surgery. Int Forum Allergy Rhinol. 2013;3(5):412–7. https://
no two frontal sinus surgeries are the same. Controversies doi.org/10.1002/alr.21109.
in frontal sinus surgery continue to be debated. It is impor- 9. Bassiouni A, Wormald PJ.  Role of frontal sinus surgery in nasal
tant to recognize that no technique will fit every situation. polyp recurrence. Laryngoscope. 2013;123(1):36–41. https://doi.
org/10.1002/lary.23610.
Consistent outcomes require familiarity with a variety of
10. Muhonen EG, Goshtasbi K, Papagiannopoulos P, Kuan EC. Appro-
techniques, combined with a surgeon’s experience, individu- priate extent of surgery for aspirin-exacerbated respiratory disease.
alized to the patient. World J Otorhinolaryngol Head Neck Surg. 2020;6(4):235–40.
https://doi.org/10.1016/j.wjorl.2020.07.005.
11. Wong EH, Do TQ, Harvey RJ, Orgain CA, Sacks R, Kalish

L.  Patient-reported olfaction improves following outside-in Draf
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 Future of Frontal Sinus Surgery: Beyond
Surgical Treatment 33
Ramón Moreno-Luna, Ainhoa García-Lliberós de Miguel,
Serafín Sánchez-Gómez, and Alfonso del Cuvillo Bernal

33.1 Introduction

33.1.1 Revision Rates for Specific Sinuses

The long-term surgical revision rate in the treatment of nasal

pathology by endonasal endoscopic surgery is one of the
most important topics in the management of patients with
chronic rhinosinusitis (CRS). There is a significant increase
in the percentage of patients requiring revision surgery in the
group of chronic rhinosinusitis with nasal polyps (CRSwNP)
compared to the group of chronic rhinosinusitis without
(sine) nasal polyps (CRSsNP) [1]. A history of previous
endonasal sinus surgery along with higher preoperative bilat-
eral Lund Kennedy Endoscopic Scores was found to be asso-
Fig. 33.1  Chronic rhinosinusitis. Frontal stenosis. Recurrence after
ciated with polyp recurrence [2], presenting different rates endoscopic sinus surgery. White star, full frontal sinus occupation. Red
for revision surgery in specific sinuses [3]. It could range star, posterior ethmoid with partial occupancy by inflamed mucosa.
from 4.2% for the anterior ethmoid sinuses to 12.4% for the Black star, posterior wall of the frontal sinus
frontal sinus [1]. Revision frontal sinusotomies were per-
formed in 21.1% of CRSwNP patients compared to only
6.3% of CRSsNP patients (p < 0.001) [1]. The frontal recess out NP, but also over other pathologies affecting this region,
around the frontal ostium followed by the frontal sinus cavity since frontal sinus is the most common site of recurrence of
are the most affected locations in polyp recurrence [4]. It is sinonasal pathology [4] (Fig. 33.1).
unclear if this circumstance occurs due to the narrowness of
the frontal ostium and the mucosal contact, because of the
residual inflammatory disease around the frontal sinus or as 33.1.2 Extension of Endonasal Endoscopic
a result of the frontal sinus poor ventilation [4]. The surgical Surgery
approach to the frontal sinus is very important to achieve
control not only over the management of CRS, with or with- Patients with narrow frontal ostia, with extensive radiologi-
cal disease, as well as different comorbidities of CRSwNP
like asthma, have a higher failure rate when standard endo-
R. Moreno-Luna (*) · S. Sánchez-Gómez
scopic frontal sinusotomy is performed, ranging from 15.9
Rhinology Unit, Department of Otolaryngology, Head and Neck
Surgery, Virgen Macarena University Hospital, Seville, Spain [1] to 20% [5]. Surgical extension has been shown to be
e-mail: [email protected] effective in reducing the polypoid recurrence rate in patients
A. G.-L. de Miguel with CRSwNP. The nasalization (i.e., complete ethmoidec-
Department of Otolaryngology, Head and Neck Surgery, Hospital tomy) [6] or the association between Draf III and extensive
de Manises, Valencia, Spain approaches during the treatment of polyposis [4] have shown
A. del Cuvillo Bernal better outcomes. Moreover, the treatment of the nasal mucosa
Rhinology and Asthma Unit, ENT Department, The University associated with the surgical extension, in patients with
Hospital of Jerez, Cadiz, Spain
CRSwNP, plays the main role in the expected results [7].
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 317
D. R. Lobo et al. (eds.), Atlas of Frontal Sinus Surgery, https://doi.org/10.1007/978-3-030-98128-0_33
318 R. Moreno-Luna et al.

mediators such as eosinophilic cationic protein (ECP),

myeloperoxidase, and IgE [13]. One of these clusters was a
non-type 2 inflammation, most frequently seen in CRSsNP
patients (comprising type 1 and type 3 immune reactions).
The other clusters were mostly based on type 2 inflammation
(moderate or severe) in CRSwNP. The type 2 inflammatory
response was characterized by a high presence of eosino-
phils, mast cells, basophils, Th2 cells, and type 2 cytokines
(IL-4, IL-5, IL-9, IL-13, IL-25, and IL-33). Severe type 2
inflammation showed significantly higher concentrations of
inflammatory cytokines compared with moderate inflamma-
tion [13].

33.2.1 Th2 Inflammation Mechanisms

in CRSwNP
Fig. 33.2  Left frontal sinus. Endoscopic view. Red star, posterior wall
of the frontal sinus. Blue star, intersinusal wall, black star, frontal beak
The mechanism that triggers the type 2 inflammatory
response in CRSwNP is yet unknown; however, it possibly
In this regard, some groups have proposed an extended endo- rests on an abnormal/pathological interaction between the
nasal surgery, named full-house functional endoscopic sinus mucosa epithelium and environment (microbes, allergens,
surgery, for revision endoscopic sinus surgery [8]. In this any other antigen, or environmental factor) through an
technical approach, they perform a maxillary antrostomy, a altered epithelial barrier function (defects in forming tight
total ethmoidectomy with a wide sphenoidotomy, and a Draf junction by the epithelial cells, genetically or environmen-
IIA frontal sinusotomy, maintaining the nonpathological tally induced). This interaction could cause epithelial layer
nasal mucosa for subsequent coverage from it [8] (Fig. 33.2). injuries that trigger an increased production of epithelial
Other groups have proposed a similarly extensive surgery, in cytokines, such as thymic stromal lymphoprotein (TSLP),
this kind of patients, by removing the sinus mucosa down to IL-25, and/or IL-33. These cytokines can initiate and amplify
the periosteum in all affected sinuses, with or without a Draf an abnormal immune type 2 polarization that generates air-
III procedure [7, 9]. In these cases, the extent of the surgery way mucosa inflammation [14] (Fig. 33.3a).
should not only include the polyps but also the thickened and TSLP binds the TSLP receptor to dendritic cells and acti-
equally diseased mucosa adjacent to them, which is also pre- vates the differentiation of Th0 lymphocytes into Th2 cells,
pared to develop polyps [10]. Alsharif et al. reported that this which produce IL-4 and tumor necrosis factor (TNF).
treatment could be a valid approach to severe cases of type 2 Additionally, TSLP activates the production of type 2 cyto-
mucosal disease involving all sinuses (reboot surgery), thus kines, such as IL-5 and IL-13, through its action on type 2
reducing relapse rates compared with conventional mucosa-­ innate lymphoid cells (ILC2) and mast cells [15]. TSLP is
sparing surgery [9]. It has been seen that the final outcomes specifically related to type 2 inflammation, whereas IL-25
could be determined by the association between the extent of and IL-33 are usually elevated in eosinophilic or non-­
the surgery and the sinus affected. eosinophilic CRS tissue. IL-25 and IL-33 contribute to the
induction of different types of inflammation under various
microenvironments [16].
33.2 From Phenotypes to Endotypes: Type ILC2 innate lymphoid cells have similar functions as Th2
2 Inflammation cells, without the complex antigen processing and presenta-
tion by dendritic cells. ILC2 responds promptly to signals
Different comorbidities like asthma, allergies, and allergic generated during epithelial injury via TSLP, IL-25, and IL-33
rhinitis are the most commonly reported in patients with and is activated in CRSwNP-releasing IL-5 and IL-13 [17].
CRSwNP and poor prognosis [11]. The inflammatory pat- In addition to the activation of ILC2, IL-33 leads to the acti-
terns in CRSwNP patients with high rates of revision surgery vation of mast cells, basophils, eosinophils, and natural killer
have different pathomechanisms, resulting in different endo- (NK) cells using the NF-kB signaling pathway [18]. IL-25 is
types, while simultaneously forming the basis for further considered a key amplification factor in type 2 inflammatory
characterization of CRSwNP [12]. In 2016, Tomassen et al. cascade that generates the activation of ILC2 and production
proposed the most accepted endotyping approach based on of IL-4, IL-5, and IL-13, an interleukin related to the remod-
an unbiased cluster analysis of inflammatory cytokines and eling process [19].
33  Future of Frontal Sinus Surgery: Beyond Surgical Treatment 319

Fig. 33.3  Biologics and their targets in type 2 inflammation in CRSwNP. chemokine receptor 3, CLC Charcot–Leyden-crystal, DC dendritic cell,
(a) Target cytokines in type 2 immune reactions. (b) Cells and mediators EOS eosinophils, IL-4R IL-4 receptor alpha, IL-13R IL-13 receptor alpha,
of type 2 inflammation and corresponding biologics. CCR-3 C–C motif neutron neutrophils. [14] (With permission from the Publisher)
320 R. Moreno-Luna et al.

Mast cell, NK, and Th2 cells produce IL-4 and IL-13 [20]. 33.3 Biological Drugs
The IL-4 enhances the type 2 inflammatory response by differ-
ent mechanisms: inducing the maturation of Th0 l­ ymphocytes 33.3.1 Criteria
into Th2 cells, upregulating IgE receptors in basophils, mast
cells, B-lymphocytes, and mononuclear phagocytic cells, The development of new specific biological drugs that tar-
increasing leukotriene levels, guiding the migration of eosino- get key players of the inflammatory process could be a
phils, basophils, monocytes, and T lymphocytes, and prevent- complementary solution to surgical approaches (precision
ing apoptosis of T lymphocytes [21]. IL-13 binds IL-13R2 and medicine) [29]. The beginning of monoclonal antibody
IL-4R, hence sharing some biological features with IL-4. (mAb) treatment in patients with chronic rhinosinusitis,
IL-13 produces local and systemic polyclonal IgE production and proven Type 2 disease, is a fundamental decision in
by plasma cells, mucus hypersecretion, subepithelial fibrosis, precision medicine. Previous surgery is an essential require-
and airway hyperresponsiveness [21]. ment at the time of proposing treatment with monoclonal
Th2 cells and ILC2 are the principal sources of IL-5, but antibodies [30].
also B cells, mast cells, basophils, epithelial cells, and eosin- The EPOS2020 consensus recommends its use in patients
ophils can generate IL-5 [19]. The IL-5 binds the IL-5-­ that failed appropriate medical therapy including functional
specific α-subunit receptor (IL-5Rα) on basophils, endoscopic sinus surgery (FESS) and corticosteroid treat-
eosinophils, and mast cells, and it is responsible for survival, ment [30]. Along with this initial antecedent, at least three
maturation, and activation of eosinophils in the bone marrow criteria must be associated with different cut-off points
and the inflammation site [19]. (Table  33.1), where the context of Th2 inflammation is
Eosinophils are key players in chronic inflammation in reinforced.
CRSwNP.  Type 2 immune response is characterized by The main studied targets correspond to intermediate medi-
marked infiltration of eosinophils and mast cells, goblet ators of the Th2 inflammatory chain (IL-4, IL-13, IL-5, IgE)
hyperplasia, and increased levels of ECP, eotaxins, total IgE, (Fig. 33.3b). The monoclonal antibodies act on these targets,
IL-5, IL-4, and IL 13 [22]. Eosinophils are a great source of such as omalizumab (IgE), mepolizumab or reslizumab (IL-
cysteinyl leukotrienes, which induce mucus hypersecretion, 5), and dupilumab (IL4 and IL13). Precision medicine can be
the release of IL-4 and IL-13, and other fibrogenic signaling achieved by combining an extended surgery associated with a
factors [19]. specific mAb (preoperatively, postoperatively, or both), thus
This inflammation could be present in polyps and non-­ controlling the future need for surgery in these patients
polypoid mucosa [10]. Interestingly, these endotypes were (Fig. 33.4). A review of the most relevant biological drugs is
associated with differences in polyp burden, the presence of beneficial to improve the management of CRSwNP patients
comorbid asthma, and the recurrence of disease after surgi- especially when the frontal sinus is affected (Table 33.2).
cal intervention. Jonstam et al. demonstrated that the muco-
sal inflammation was not limited to the polyps themselves
and was equally present in the non-polypoid sinus mucosa 33.3.2 Dupilumab
[10]. This situation maintained extensive mucosal inflamma-
tion and inflammatory triggers leading to relapse around the Dupilumab is a human monoclonal antibody with a role in
nasal polyps. The reboot surgery, in which both polyps and type 2 inflammation [31], targeting the α chain of the inter-
non-polypoid sinus mucosa are removed, decreased type 2 leukin (IL)-4 receptor. There are two types of IL-4 receptors:
inflammatory markers in nasal secretions after surgery [10] type 1, composed of the IL-4Rα and γ chain, and type 2,
for at least 12  months although it might not be enough to composed of the IL-4Rα chain and the α1 chain of the IL-13
control the disease. receptor [32]. The main function of dupilumab is to inhibit
The use of some biological drugs such as monoclonal IL-4 and IL-13 cytokine-induced responses by specifically
antibodies has increased in recent years for the treatment of binding to the IL-4 receptor alpha subunit, which is shared
inflammatory pathologies (Th2 inflammation) like asthma, by the IL-4 and IL-13 receptor complexes (Fig. 33.5).
dermatitis, and even CRSwNP. Monoclonal antibodies might IL-4/IL-13 receptors are present on the surface of a large
decrease type 2 biomarker levels in nasal polyp tissues [23] number of cells involved in the pathophysiology of Th2
with positive outcomes in clinical, endoscopic, and radio- allergic responses. They also play a role in the immunologi-
logical findings, even reducing the need for surgery [24–27]. cal mechanisms underlying the defective function of the epi-
A precision treatment that combines endotypes, the extent of thelial cells tight junction [33].
surgery techniques (extended or reboot surgery), and mono- The efficacy and safety profile of dupilumab was tested in
clonal antibodies could certainly be useful to control patients the treatment of patients with asthma and atopic dermatitis
with type 2 CRSwNP [28], especially when very complex [34]. Recently, it has been shown a meaningful reduction in
regions such as the frontal sinus are affected. the annualized rate of severe asthma exacerbations in addi-
33  Future of Frontal Sinus Surgery: Beyond Surgical Treatment 321

Table 33.1  Criteria for the use Presence of bilateral polyps in a patient who had EES
of monoclonal antibodies
published in the EPOS2020 +3 criteria
guide [30]

CRITERIA CUT-OFF-POINTS

Evidence of type 2 inflammation Tissue eos≥10 hpf, or lood eos≥250, or

Need for systemic corticosteroids total IgE≥100
(or contraindications) ≥2 courses per yr or long term low dose
Impaired quality of life steroids
Loss of smell SNOT-22≥40
Comorbid Asthma Anosmic
Asthma needing inhaled corticosteroids

EES, endonasal endoscopic surgery, Eos eosinophilia, HPF high power field, SNOT-22 sino-nasal outcome test

severity but also achieved a significant improvement in

HRQoL and productivity (assessed by SNOT-22) [38, 39].
Interestingly, they also observed a decrease in multiple type
2 inflammation biomarkers in nasal secretions and polyp tis-
sue in patients with CRSwNP [23].
Two-phase III clinical studies were recently published
Monoclonal Extent
Antibodies surgery evaluating the efficacy of dupilumab in reducing the severity
of nasal congestion/obstruction and endoscopic nasal polyp
score, in adults also treated with intranasal corticosteroids
for 24 weeks (SINUS-24) and 52 weeks (SINUS-52) [40].
Dupilumab significantly improved the coprimary endpoints
Inflammatory
in both studies reducing polyp size and symptom severity
patterns (nasal congestion and obstruction). Lund–Mackay CT and
(Endotypes) UPSIT scores also showed a marked improvement in both
the studies. Dupilumab reported the reduction in both sur-
gery and oral corticosteroids (OCS) use, as a composite out-
come [40], thereby offering an efficacious treatment for
patients with severe CRSwNP. Other subanalysis was carried
Fig. 33.4  Precision medicine. Combination of an extended surgery out in the patients included in the trial with previous ESS, in
associated to a specific monoclonal antibody and endotypes
which an improvement in endoscopic and radiological find-
ings was observed when the start of treatment with dupil-
tion to an improvement in the absolute forced expiratory vol- umab was closer to surgery (<3 years) [41]. These outcomes
ume at first second (FEV1) in patients with eosinophil counts may suggest its use after nasal surgery in severe nasal pol-
> 150 cells/mm3. Elevated eosinophil counts may potentiate yposis in the context of tailored medical treatment.
a dual-blocking effect of dupilumab on both IL-4 and IL-13 Although there were no real-life studies in CRSwNP at the
[35]. The benefits of dupilumab on sinusitis in patients with time of writing this document, dupilumab was reinforced as an
asthma have been previously described [36]. add-on treatment in adults with severe uncontrolled CRSwNP
In 2016, Bachertt et al. published a study in which subcu- in a recent systematic review. It reduces the need for rescue in
taneous dupilumab (600  mg loading dose followed by NP surgery and/or for OCS with moderate certainty, and
300 mg) plus mometasone furoate nasal spray administered improves, with high certainty and with a safety profile, the
for 16  weeks showed a significant improvement in endo- sense of smell, the quality of life, the nasal polyp score, and
scopic, clinical, and radiographic outcomes over placebo the CT score [27]. The favorable findings resulted in the
[37]. Subsequently, additional outcomes of this study were approval of dupilumab by the US FDA in June 2019 as the first
published in which dupilumab not only reduced disease biologic for the treatment of CRSwNP ­ (https://www.ema.
322 R. Moreno-Luna et al.

Table 33.2  Biological drugs in CRSwNP

PRINCIPAL OUTCOMES
Study
DOSE
(NAME/ PARTICIPANTS
Mab (description/ TARGET AE
phase/ (Enrollment)
period)
IP/Identifier) NASAL
SIMPTOMS RADIOLOGICAL
NPS FINDINGS SURGERY QoL Olfaction
(NO/NC/RN/PD)

Phase 2 600 mg SC/300mg

Reduction Lund-
Bachert et al, SC Reduction in Improvements
51 - Mackay CT total - - Nasopharyngitis
2016 (34) every week NPS 16 wk SNOT-22
score
NCT01920893 (16wk)

SINUS-24
Phase 3 300mg SC
Bachert et al, every 2 weeks 276 Improvements
Reduction of Reduction of Nassal Difference in Lund- Improvements
2019 (37) (24wk) UPSIT Nasopharyngitis
NPS 24 wk Congestions Mackay CT scores SNOT-22
NCT02912468 Blocks IL- (< anosmia)
Dupilumab
4Ra receptor Less Surgery
NPS and LMK were
300 mg SC and/or
greater in patients with
every 2 weeks SCS
SINUS-52 <3 years since
(52wk) (composite
Phase 3 last surgery
300 mg SC outcomes)
Bachert et al, 448 Improvements
every 2 weeks Reduction of Reduction of Nassal Difference in Lund- Improvements
2019 (37) UPSIT Nasopharyngitis
(24wk) NPS 52 wk Congestions Mackay CT scores SNOT-22
NCT02898454 (< anosmia)
and every 4 weeks
(until 52wk)

Improvements
Phase 2
Based on total Lund -Mackay score. QoL:
Gevaert et al, Reduction of
serum IgE levels 24 - CT images improved - -AQLQ score - Mild
2012 (40) NPS (16 wk)
and body weight (16 wk) -RSOM-31
NCT01066104
score
POLYPS 1
Gevaert et al,
Binds free
Omalizumab 2020(45) 138
IgE
Phase 3 75 to 600 mg by Improvements Improvements in need for surgery: NPS
NCT03280550 Reduction of
subcutaneous IN sense of smell, <4 (unilateral score <2 on each side) and Improvements Improvements
NPS - Mild
POLYPS 2 injection every 2 postnasal drip, runny SNOT-22 score improvement >8.9 SNOT-22 UPSIT
(24 week)
Gevaert et al, or 4 weeks nose at week 24 (MCID)
2020(45) 127
Phase 3
NCT03280537

Improvements VAS
Bachert et al
750 mg IV (rhinorrhea, mucus in Improvements No
2017(24) Improvements Reduced Need for surgery (Week 25)
every 4 weeks (6 105 the throat, nasal - SNOT-22 improvements Mild
Phase 2 NPS Composite end point (NPS / VAS global)
doses) blockage, and loss of (week 25) Sniffin’ Sticks
NCT01362244
smell) (Week 25)

Mepolizumab Inhibits IL-5

SYNAPSE Improvements VAS
JK Han et al(56), 100 mg SC Improvements (Nasal obstruction) Improvements
Nasopharyngitis
(2021) 13 doses 407 NPS (overall, composite, - No mention SNOT-22 -
and headache
Phase 3 every 4 weeks (Week 52) loss of smell) (Week 52)
NCT03085797 (Week 52)

NPS nasal polyps score, QoL quality of life, AE adverse events, wk weeks, SNOT-22 Sino-Nasal Outcome Test 22, AQLQ Asthma Quality of Life
Questionnaire, RSOM-31 Rhinosinusitis Outcome Measuring Instrument, MCID Minimal Clinically Important Difference, UPSIT University of
Pennsylvania Smell Identification Test, VAS visual analog scale, SCS systemic corticosteroids

Fig. 33.5 Monoclonal
antibody (dupilumab)
targeting the IL-4Rα [14] DUPILUMAB

IL-4Rα γc IL-4Rα IL-13Rα

33  Future of Frontal Sinus Surgery: Beyond Surgical Treatment 323

europa.eu/en/medicines/human/EPAR/dupixent). However, both CRSwNP and asthma. The dose and frequency used
more research is required to assess the cost effectiveness of were based on total serum IgE and body weight with a maxi-
this treatment relative to surgery [42]. mum of 375 mg twice a month or monthly [43].
After this first proof-of-concept study, Gevaert et al. [48]
carried out two international (identical) multicenter trials
33.3.3 Omalizumab evaluating the efficacy and safety of omalizumab in patients
with inadequately controlled CRSwNP.  A significant
Omalizumab is a humanized monoclonal antibody that binds improvement was found in coprimary endpoints (nasal polyp
free circulating IgE and prevents the binding of IgE to the score and nasal congestion score) in both the trials, along
high-affinity IgE receptor (Fc∑RI), thus reducing the with significant enhancements for SNOT-22 score, UPSIT
amount of free IgE levels. Furthermore, omalizumab leads to score, total nasal symptom score, individual nasal symptoms
a decrease in IgE receptors on mast cells, basophils, and den- (sense of smell, postnasal drip, runny nose), and AQLQ
dritic cells impeding their degranulation [16, 43] (Fig. 33.6). (asthma-related score) from baseline to week 24. It should be
Due to its demonstrated potential benefits, omalizumab highlighted that the important decrease in SNOT-22 score
is being used for the treatment of persistent severe allergic after treatment with omalizumab was similar to that reported
asthma and chronic spontaneous urticaria (CSU) in recent after functional endoscopic sinus surgery (FESS) [50].
years. Currently, it is also indicated as add-on therapy with Lastly, a reduced need for surgery and rescue therapy by
intranasal corticosteroids for the treatment of adults week 24 was appreciated, even so, with no statistical signifi-
(18 years and above) with severe CRSwNP, for whom tra- cance [48, 51]. An extension study of POLYP (OLE Study)
ditional medical and surgical therapy does not provide ade- showing results of up to 52  weeks of treatment is pending
quate disease control. The latter indication has recently publication.
been approved by the European and American Medicines It is interesting to mention two real-life studies in which
Agency and included in the technical data sheet (Xolair; the beneficial effects of omalizumab in patients with severe
Novartis, Basel, Switzerland). Multiple studies and trials CRSwNP and asthma have been proved. Blidder et al. [47]
have proved the efficacy of omalizumab in a real-world set- reported a study in a group of patients diagnosed with
ting [43–49]. CRSwNP and severe asthma. They compared the response
Gevaert et al. [43] conducted the first randomized, double-­ between treatment with omalizumab (n = 13) and treatment
blind, placebo-controlled trial investigating the effectiveness with FESS (n = 24) by using the SNOT-22 and asthma con-
of omalizumab in 24 patients with CRSwNP and comorbid trol questionnaire ACQ-7. No statistical difference was
asthma. After 16 weeks, omalizumab significantly improved found in the median SNOT-22 between the omalizumab-
endoscopic NPS, Lund–Mackay score, and asthma symp- and surgery-treated groups underlining the rapid and paral-
toms scores and questionnaires. These findings supported the lel improvement in both groups as early as 4  weeks post
importance of local polyclonal IgE in the pathophysiology of treatment. This fact brings to light the importance of treat-
ing the one airway with one drug. On the other hand,
Armengot et al. [49] evaluated the effects of omalizumab on
OMALZUMAB nasal polyps size and SNOT-22 in 23 patients with recalci-
trant CRSwNP and mild asthma (19 of them suffered from
nonsteroidal anti-inflammatory drug [NSAID] exacerbated
respiratory disease [NERD]) showing a very homogeneous
sample. They highlighted that the SNOT-22 improvements
were not explained by the changes observed in nasal polyp
IgE
size or other variables (IgE levels or eosinophilia), which
FcεR led them to hypothesize that the decrease in submucosal
FcεR inflammation may improve subjective patient symptoms
(including asthma) in a manner not directly proportional to
the polyp size. This fact could be explained by the great
response found in CRSwNP and asthma in the 19 patients
with NERD, given that omalizumab is thought to be a mast
cell stabilizer [52, 53].
Regarding the responders established to date for omali-
Mast cell zumab, Periostin has been seen as a marker for omalizumab
Basophil
responsiveness in patients with asthma, so it is also likely
Fig. 33.6  Monoclonal antibody (omalizumab) targeting the IgE [14] relevant in eosinophilic nasal polyposis since it is secreted
324 R. Moreno-Luna et al.

by mast cells via IgE-mediated response [54]. Asthma reach statistical significance, but it was suggested that the
comorbidity did not appear to be a significant predictor of study was too short [56].
response [48], so determining tissue endotype and develop- Bachert et  al. published a phase II trial, in which 105
ing biomarkers could be important to conduct better patient patients with recurrent CRSwNP requiring surgery received
selection and to obtain better treatment responses with 750  mg of intravenous mepolizumab or placebo every
omalizumab. 4  weeks for a total of 6 doses, in addition to daily topical
Additionally, omalizumab was well tolerated, and adverse corticosteroid treatment [24]. This trial aimed to assess the
effects were mild (headache, injection site reactions, arthral- percentage of patients who no longer required surgery at
gia, dizziness, and abdominal pain) and concordant across week 25 based on a composite of endoscopic polyp score
all studies carried out so far. A long-term follow-up will be (EPS < 3) together with the severity obtained in the visual
essential to determine the frequency of these events and to analog scale (VAS  <  7). Thirty percent of patients in the
determine other unforeseen events associated [48, 51]. mepolizumab group versus 10% in the placebo group reached
the primary endpoint to avoid the need for surgery (p = 0.006).
There was also a significant improvement in the total endo-
33.3.4 Mepolizumab scopic nasal polyp score (TNPS) and the odds ratio for being
a responder (improvement higher than 1 point in TNPS) was
Mepolizumab (SB-240563) is a humanized immunoglobulin 6.6 (p  =  0.025). Visual analog scale (VAS) scores for
G1 kappa (IgG1k) monoclonal antibody. It recognizes and CRSwNP severity and sino-nasal outcome test (SNOT-22)
neutralizes free IL-5 and prevents its binding to IL-5Rα, thus scores were remarkably improved in the mepolizumab group
reducing blood and sputum eosinophil counts [55] (Fig. 33.7). compared with the placebo group with a safety profile of the
Gevaert et al. assessed mepolizumab in a small group of treatment.
patients with severe recurrent CRSwNP, refractory to topical A phase III trial, “SYNAPSE” (Study in Nasal Polyps
glucocorticoid therapy, after surgery, in a double-blind, ran- Patients to Assess the Safety and Efficacy of Mepolizumab),
domized, placebo-controlled study. Twelve out of 20 patients was recently published [57]. This trial aimed to assess the
receiving mepolizumab (two single intravenous injections of clinical efficacy and safety of mepolizumab (100 mg SC, 13
750 mg of mepolizumab) had a significant improvement in doses) in adults with severe bilateral nasal polyps. It has
the endoscopic polyp score and computed tomography scan reported that total endoscopic NPS notably improved
score at week 8 versus baseline. Improvements in symptom (p < 0.001) with mepolizumab (n = 206) compared to pla-
scores (loss of smell, post-nasal drip, and congestion) did not cebo (n  =  201) [58], ameliorating SNOT-22 and
VAS. Curiously, the outcomes obtained in a real-life study
differ from previous results in severe eosinophilic asthma
Eosoinophil
(SEA) with concomitant CRSwNP patients, where patients
responded favorably to mepolizumab, in terms of asthma
control, while their CRSwNP disease persisted and, in some
βc
cases, continued to worsen [59]. However, this lack of effi-
IL-5 cacy could be explained by an insufficient dose of mepoli-
zumab in the referred study.
IL-5Rα There is no increment of the overall incidence of adverse
events (AE) in treatment with mepolizumab in asthmatic
patients [60] with a safety profile comparable with placebo
also in patients with recurrent nasal polyposis [24]. The most
frequently reported AE were nasopharyngitis and headache
[24, 58, 60].

33.3.5 Reslizumab

Reslizumab is an IgG4/k humanized monoclonal antibody

that prevents IL-5 from binding to the IL-5Rα subunit
MEPOLIZUMAB expressed on the surface of eosinophils, thus depleting their
levels [61]. Simon et al. demonstrated in vitro that treatment
of eosinophil-infiltrated polyp tissue with neutralizing anti-­
Fig. 33.7  Monoclonal antibody (mepolizumab) targeting the IL-5 [14] IL-­5 mAb resulted in eosinophil apoptosis and decreased tis-
33  Future of Frontal Sinus Surgery: Beyond Surgical Treatment 325

sue eosinophilia [62] reducing blood and sputum eosinophils 33.4 Future Research
in mild-to-severe asthma [63, 64]. The FDA approved its use
in March 2016 for add-on maintenance of severe eosino- Many topics need to be investigated in this field. More preci-
philic asthma in patients aged 18 years and older. sion in the application of monoclonal antibodies and the
Castro et  al. conducted a randomized controlled trial extent of the surgery is required. These are some proposals
(RCT) [61] to evaluate the effect of reslizumab in patients for future research:
with poorly controlled eosinophilic asthma, where patients
who presented comorbid nasal polyposis reported a signifi- • Identify the different CRSwNP phenotypes and the best
cant improvement in Asthma Control Questionnaire scores monoclonal antibodies for combined treatments and the
[65]. Gevaert et al. [66] carried out a phase I trial in patients best therapeutical approach for each phenotype.
with nasal polyps with a high endoscopic nasal polyp score • Which cells and mediators are crucial to target in order to
(EPS) or recurrent nasal polyposis after surgery. In a short optimize the approach with biological drugs?
period (4–12 weeks), there was an improved EPS in patients • Further investigation is needed to clarify the clinically rel-
with higher IL-5 levels in nasal secretions compared with evant biomarkers to direct the choice of mAb in order to
non-responders, subsequently behaving as a predictor of achieve the optimal treatment pathways based on preci-
response to anti-IL-5 treatment. Two other remarkable sion medicine.
parameters that decreased compared with placebo were • Head-to-head comparisons of biologicals in CRSwNP are
eosinophilic cationic protein (ECP) and secreted IL-5α for lacking.
the first few weeks after treatment. Even so, in different sys-
tematic reviews, the evidence of efficacy in CRSwNP is still
uncertain for reslizumab [27]. 33.5 Conclusions
A single dose of reslizumab was well tolerated across the
studies. The majority of the adverse events reported were • Frontal sinus has been shown to be the nasal sinus most
minor, with the most common being upper respiratory tract strongly associated with higher surgical revision rates in
infections [66]. Th2 inflammatory nasal pathology.
• Endonasal surgical extension permits better control and
management of Th2 inflammatory pathology.
33.3.6 Others Potential mAb: Benralizumab, • The impact that different monoclonal antibodies have on
Tezepelumab surgical revision rates should be comprehensively ana-
lyzed in order to obtain improved eligibility criteria. This
Benralizumab is an anti-IL-5 monoclonal antibody which would allow for a more helpful comparison between treat-
binds to the alpha chain of the IL-5 receptor (IL5Rα) origi- ments to be made, as well as a more precise definition of
nating a direct depletion of eosinophils levels, within 24 h, their indications.
through enhancing the antibody-dependent cell-mediated • Further studies and research are still necessary to develop
cytotoxic pathway with the assistance of natural killer cells precision medicine approaches in the management of
[67] (Astrazeneca, Cambridge, UK). The FDA approved its frontal sinus pathology.
use in November 2017 for add-on maintenance of SEA in
patients aged 12  years and older [68]. Real-life studies in
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