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Babak Saedi Associate Professor of Department of Otolaryngology Tehran University of Medical Sciences. Frontal Sinus Surgery. Anatomy. Uncinate process Agger Nasi.

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Babak Saedi

Associate Professor of Department of Otolaryngology

Tehran University of Medical Sciences

Frontal Sinus Surgery

  • Uncinate process
  • Agger Nasi

  • Cribriform Plate
  • Lamina papyracea
  • Fovea ethmoidalis
uncinate process

Uncinate Process

Wormald PJ 2008


A common reason for ESS failure is inadequate removal of cells obstructing the outflow of the frontal sinus

frontal cells
Frontal Cells

Kuhn FA 1994

frontal cells1
Frontal Cells
  • Type I - Single cell above the agger nasi
  • Type II - Two or more cells above the agger cell
  • Type III - Single cell extending from the agger cell into the frontal sinus
  • Type IV - Isolated cell within the frontal sinus
surgical indications
Surgical Indications
  • Chronic sinusitis unresolved with maximal medical therapy;
  • Polyps and allergic fungal sinusitis
  • Intracranial complications of sinusitis
  • Mucoceles or mucopyoceles
  • Benign neoplasms such as osteomas, inverting papillomas, or fibrous dysplasia.
endoscopic frontal sinusotomy
Endoscopic Frontal Sinusotomy
  • Understand the patient’s frontal recess anatomy
  • Ascertain the anatomical reason for frontal recess/frontal sinus obstruction
  • Determine the best surgical approach to the problem
endoscopic frontal sinusotomy principles
Endoscopic Frontal SinusotomyPrinciples
  • Dissection should be performed from posterior to anterior and from medial to lateral
  • Preserve all frontal recess mucus membrane
  • The frontal ostium can be stented or left alone!!!!

Kuhn FA 2006


draf i
Draf I
  • Anterior ethmoid cells
  • Uncinate process
  • Obstructing frontal cells
draf ii
Draf II
  • Floor of the frontal sinus
  • Lamina papyracea to Septum
  • Anterior face of Frontal
draf iii
Draf III
  • Modified Lothrop
  • Interfrontal septum
  • Nasal septum
  • Frontal sinus floor
surgical outcomes following the endoscopic modified lothrop procedure
Surgical Outcomes Following the EndoscopicModified Lothrop Procedure
  • Conclusion: EMLP is a safe and effective surgical alternative to OPF for patients with recalcitrant frontal

sinus disease. Major complications are rare. A large percentage of patients may require revision surgery

Laryngoscope, 117:765–769, 2007

frontal sinus trephination
Frontal Sinus Trephination
  • Finding the frontal recess
  • Mucoceles
  • Isolated Type IV frontal cells
  • With endoscopic techniques to assist with Draf II and III
endoscopic frontal sinoplasty
Endoscopic Frontal Sinoplasty
  • The least invasive procedure
  • It can be used as a stand-alone procedure or with ethmoidectomy
  • It pushes the medial aggernasi cell wall laterally and the ethmoid bulla lamella posteriorly
  • K

Kuhn FA 2006

osteoplastic flap vs draf iii
Osteoplastic Flap Vs. Draf III
  • Narrow Nasal Airway
  • Small Frontal Sinus
  • Deep Nasion
  • Floor of sinus < 1.5 cm
  • Heavy thick nasofrontal beak
  • Proliferative osteitis, complicated chronic infection
  • Favor Draf III for mucoceles
the frontal osteoplastic flap does it still have a place in rhinological surgery
The frontal osteoplastic flap: does it still havea place in rhinological surgery
  • The frontal osteoplastic flap still has a role in frontal sinus surgery.

The Journal of Laryngology & Otology (2011), 125, 162–168.

osteoplastic flap approach
Osteoplastic Flap Approach
  • Osteoplastic and endoscopic (above and below approach)
  • Frontal sinus obliteration

Wynn R, et al 2007

riedel s procedure
Riedel's Procedure
  • Osteomyelitis of the anterior wall of the frontal sinus
  • Failure of frontal sinus obliteration
  • Some tumors of the frontal sinus
pearl 1 carefully examine the anatomy in more than one ct plane
Pearl #1 Carefully Examine the Anatomy in more than one CT plane
  • Size of the frontal recess
  • Size of the frontal sinus
  • Bony thickening or neo-osteogenesis
  • Identify the frontal sinus drainage pathway
  • Note the position of the anterior ethmoidal artery
pearl 2 identify the anterior ethmoidal artery
Pearl # 2 Identify the Anterior Ethmoidal Artery
  • Superior extension of anterior wall of bulla
  • Nipple on the medial orbital wall
  • 1-4 mm’s below skull base
  • Typically posterior to supraorbital ethmoid cells
pearl 3 plan the least invasive approach possible
Pearl #3: Plan the least invasive approach possible
  • Ethmoidectomy with Middle Meatal Antrostomy without frontal recess surgery
  • Frontal recess surgery
  • Endoscopic frontal sinusotomy
  • Frontal sinus trephination
  • Unilateral extend frontal sinus surgery (Draf II)
  • Endoscopic Modified Lothrop (Draf III)
  • Osteoplastic flap with or without obliteration
pearl 4 positively identify the skull base posteriorly
Pearl #4 Positively Identify the Skull Base Posteriorly
  • Skeletonize from posterior to anterior
  • Open cells immediately posterior to the middle turbinate
  • Identify the sinus with a seeker
pearl 5 positively identify the frontal sinus with a probe
Pearl #5 Positively identify the frontal sinus with a probe
  • Need a relatively dry field
  • 45 degree telescopes are helpful
  • Identify medial orbital wall and stay close to it dissecting superiorly
  • Opening to frontal sinus typically medial
  • Identify opening with a probe
pearl 6 preserve the mucosa
Pearl # 6 Preserve the Mucosa
  • Consider leaving polyps if sinus is open
  • Remove osteitic intersinus septae carefully
  • Do not traumatize unless sinus can be opened widely
  • Standard frontal sinusotomy
    • Draf Type II
    • Works well if you can:
      • Preserve mucosa
      • Remove bony partitions
      • Create an ostium >4-5 mm
pearl 7 keep the sinus open postoperatively
Pearl #7 Keep the Sinus Open Postoperatively
  • Remove fibrin and blood from frontal recess and frontal sinus
  • Remove residual bone
  • Antibiotics, topical steroids?
  • Oral Steroids?
  • Very little evidence based medicine
  • Do the least invasive procedures first
  • Be aware of various surgical options
  • Image guidance a valuable tool
  • First do no harm