FRONTAL SINUS PROCEDURES

1. FRONTAL SINUS
PROCEDURES
DR. AJAY MANICKAM
MS ENT PGT
RG KAR MEDICAL COLLEGE

2. Comprehensive Anatomy
O Varies remarkably in size, degree of
septation, drainage configuration
O Drainage is downwards – acute sinusitis
heals fast, chronic is less frequent
O Width and course of fronto nasal recess
depends on size & number of ant etmoidal
cells

3. The Frontal sinus
O Upper dome
attachment of
Uncinate process
within frontal recess
described by
Stammberger as Egg
shell in an inverted cup
O Hour Glass
Configuration – Frontal
infundibulum, Frontal
ostium, Frontal Recess

4. Endoscopic view
O The upper border of
attachment of
uncinate process is
removed
O Bulla removed
systematically

5. Frontal Cells
O Anterior ethmoidal air cell can migrate to
frontal recess area – Frontal Cells
O Type 1 – single above agger nasi cell
O Type 2 – multiple cell above agger nasi
O Type 3 – a cell into frontal sinus
O Type 4 – isolated loner cell within frontal
sinus

6. Type 1 and Type 2 cell

7. Type 3 and Type 4 cell

8. Clinical Diagnosis
O History
O Clinical Examination
1. Inspection
2. Palpation
3. Percussion
4. Ant Rhinoscopy & Endoscopy
O Imaging
O Plain X ray
O CT & MRI
O Scintigraphy

9. Pathology
O Fronto Basal malformations
O Trauma of the Frontal sinus
O Inflamatory diseases
O Frontal Pneumosinus dilatans
O Tumours

10. Frontobasal malformations
O Classification
O Site of herniation
O Contents of the sac

11. Frontobasal malformations
OFronto basal occult or
manifest?
OCT & MRI ESSENTIAL
OWhole skull base – Multi
locular defects

12. Operative principle
O Nasal fistulas and cyst – short ones
endoscopically, larger via external
approach
O Meningo and encephalocele endonasal
approach
O Very large meningo encephalocele
preferably external via coronal approach

13. Trauma of Frontal sinus
O CT imaging & MRI
O Comminuted fracture post wall – dural
lacerations – has to be ruled out
O Principles
O No wait & see
O PNS is not sterile – ascending intracranial
O Earlier Riedel’s operation

14. 3 Individual situations
O Fracture of anterior and/or posterior wall
but intact KILLIAN’S infundibulum
O Severely comminuted fracture
O Fractures of the orbital roof

15. Dural Lesion
O Underlay technique between brain & dura
O Underlay technique between dura & bone
O Onlay technique onto the posterior wall of
the frontal sinus

16. Inflammatory Diseases
O Frontal sinus trephenation and endoscopy
O External fronto ethmoidectomy
O Endonasal surgery of the frontal sinus
O Rhinofrontal sinuseptomy
O Osteoplastic bone flap procedure
O Cranialization of the frontal sinus

17. Frontal sinus trephanation

18. External
frontoethmoidectomy

19. Endonasal surgery
O Type 1 – simple drainage
O Type 2 – extended drainage
O Type 3 – endonasal median drainage

20. Type 1
OSimple drainage
established by
ethmoidectomy.
Inferior part is
untouched.
OMinor pathology

21. Type 2
O Resecting floor of
frontal sinus
between lamina
papyracea and the
middle turbinate
(2a) or the nasal
septum (2b)

22. Type 3
O 2b is enlarged by
resecting nasal septum.
The diameter is about
1.5 cm.
O Starting on oneside
crossing midline
contralateral lamina
papyracea is reached.

23. Rhinofrontal sinuseptotomy
O External approach jansen-ritter approach
O Resection of frontal sinus pathology
O Total resection of frontal intersinus septum
O Partial endonasal rection of the nasal
septum
O Bilateral endoscopic ethmoidectomy
O Complete epithelization with free mucosal
grafts.

24. Osteoplastic bone flap
procedure

25. Cranialization of the frontal
sinus
O Initial part similar to osteoplastic frontal
sinus procedure
O After careful mobilization of the dura
eventual duraplasty, post wall of frontal
sinus completely removed.
O Dead space between ant wall and dura
obliterated abdominal fat.

26. Frontal pneumosinus dilatans
O Pneumatization varies
between individuals
O Pneumatization may extend
beyond the confines of the
frontal bone.
O May be associated with
arachnoid cysts,
meningioma, fibrous
dysplasia
O Cranio cerebral hemiatrophy
(Dyke –Davidoff-Masson
syndrome)

27. Tumours
O Endonasal
O Midfacial degloving
O Subcranial
O Lateral rhinotomy justified only if orbital
exenteration is necessary

28. Benign frontal sinus neoplasm
O Not extending more laterally than a
vertical plane through the lamina –
endonasal
O Point of origin posterior lower third –
endonasal & if there is fixation at ant wall
of frontal sinus contraindicated
O Intracranial extension – degree &
experience of surgeon

29. Endoscopic surgery of
Osteoma

30. Open approach

31. Fibrous dysplasia
O Tumour like lesion – self limiting – non
encapsulated
O 3 types
O Monostotic
O Polyostotic
O mcCune Albright syndrome

32. Communited fracture

33. Conclusion
O Bony borders outlet intact and preserving
mucosa as much as possible offer less
morbidity.
O If endo nasal procedure is not leading to
success then osteoplastic frontal sinus
operation results in 90% solution.

34. Thank you