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Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique.
Stammberger H, Posawetz W.
ENT-Hospital, University of Graz, Austria.
The Messerklinger technique is a primarily diagnostic endoscopic concept demonstrating that the frontal and the maxillary sinuses are subordinate cavities. Disease usually starts in the nose and spreads through the ethmoidal prechambers to the frontal and maxillary sinuses, with infections of these latter sinuses thus usually being of secondary nature. Standard rhinoscopy and sinus X-rays are frequently not sufficient to demonstrate the underlying causes for chronic or recurring acute sinusitis in the clefts of the anterior ethmoidal sinuses. The combination of diagnostic endoscopy of the lateral nasal wall with conventional or computed tomography in the coronal plane has proven to be the ideal method for the examination of inflammatory disease of the paranasal sinuses. In so doing, diseases and lesions that otherwise might have gone undiagnosed can be identified and consequently treated. Based on this diagnostic approach, an endoscopic surgical concept was developed, aiming for the underlying causes of sinus diseases instead of the secondarily involved larger sinuses. With usually very limited surgical procedures, diseased ethmoid compartments are operated on, stenotic clefts widened and prechambers to the frontal and maxillary sinuses freed from disease. In our experience, there is rarely a need for major manipulations inside the larger sinuses per se. Based on exact diagnosis, the surgical technique used allows a very individualized staging according to the prevailing pathology. In the extreme, a total sphenoethmoidectomy can be performed with this technique, although the true advantage of the technique is that even in cases of massive disease such radical procedures can be avoided. By reestablishing sinus ventilation and drainage via the natural ostia, there is also no need for fenestration of the inferior meatus. The Messerklinger technique can be applied to a wide spectrum of indications, apart from nasal polyposis. The technique has its clear limits as well as its specific problems. Adequate training and experience are required for the surgical approach, as the technique bears all the risks and hazards of all kinds of endonasal ethmoid surgery but has a minimal complication rate in the hands of an experienced surgeon. Results and complications of a series of more than 4500 patients over a period of over 10 years are presented and discussed in detail.
Nasal and paranasal sinus endoscopy. A diagnostic and surgical approach to recurrent sinusitis.
Stammberger H.
Our endoscopic concept of the diagnosis and surgical treatment of recurrent sinusitis is based on Messerklinger's finding that almost all infections of the frontal and maxillary sinuses are rhinogenic. They are secondary to infection foci in their prechambers in the anterior ethmoid, especially in the ethmoidal infundibulum and the frontal recess, spreading from there to the dependent larger sinuses. Consequently, our functional endoscopic sinus surgery is aimed at these infection foci in the ethmoid, clearing mucosal contact areas, stenotic clefts and diseased cells. Ventilation and drainage of frontal and maxillary sinuses are re-established via their natural routes. There is no need for fenestration via the inferior meatus. Disease in the larger sinuses then usually heals without the mucosa having actually been touched. In our experience, this leaves hardly any indication for external or more radical procedures. The technique of endoscopic diagnosis and surgery are described in detail.
[Personal endoscopic operative technic for the lateral nasal wall--an endoscopic surgery concept in the treatment of inflammatory diseases of the paranasal sinuses]
[Article in German]
Stammberger H.
Many years of endoscopical investigation and observation have shown that most infections of the PNS are rhinogenic, spreading from the nose into the sinuses. Usually, a focus of infection in recurring sinusitis remains in stenotic areas of the anterior ethmoid, reinfecting the larger sinuses time and again. The anterior ethmoid, especially its infundibulum, thus holds a key position for reinfection or cure, and maxillary as well as frontal sinuses are fully dependent on the pathophysiological conditions obtaining in the anterior ethmoid. Endoscopic endonasal surgery under guidance of rigid endoscopes consequently aims at these primary focuses in the anterior ethmoid, clearing stenotic clefts and infected ethmoidal cells of diseased mucosa. For drainage and ventilation, the maxillary ostium is enlarged into the anterior nasal fontanelle. There is no need for any fenstration into the inferior nasal meatus. Once the ethmoidal focus is cleared, the dependent larger sinuses usually heal without having been touched themselves - even if their mucosal pathologies seemed almost irreversible. The endoscopic procedure, which is carried out in local and surface anaesthesia (excepting children) is described in detail. Excellent results with this method developed by Messerklinger, indicate that there is hardly any indication left for a Caldwell-Luc procedure in chronic recurring sinusitis.
[Complications of endonasal surgery of the paranasal sinuses. Incidence and strategies for prevention]
[Article in German]
Rudert H, Maune S, Mahnke CG.
Klinik fur Hals-. Nasen-, Ohrenheilkunde, Kopf- und Halschirurgie, Christian-Albrechts-Universitat zu Kiel.
BACKGROUND: Complications of endonasal surgery continue to occur despite improved optical instruments and surgical techniques. The clinical course of our patients was analysed to develop strategies for a safer surgical technique. PATIENTS: At the Department of Otorhinolaryngology, Head and Neck Surgery, University of Kiel, 1172 patients (2010 operated sides) were treated between 1986 and 1990 for chronic sinusitis by endonasal paranasal sinus surgery. RESULTS: The following intraoperative complications were observed: dural injury in 0.8% of the patients (0.5% of the operated sides), retrobulbar hematomas in 0.25% of the patients (0.15% of the operated sides), and hemorrhages requiring transfusion in 0.8% of the patients (0.5% of the operated sides). No injuries of the orbital muscles, the optic nerve, or the carotid artery were observed. Endonasal dacryocystorhinostomy was performed in 195 patients, 15% of whom had previously had paranasal sinus surgery. Endonasal frontal sinus surgery type II or III was performed in 40 patients between 1953 and 1993. A past surgical history-mostly extranasal frontal sinus surgery according to Ritter-Jansen and Lathrop-was found in 80% of these patients. Of 12 mucoceles of the frontal sinuses, 10 had developed after extranasal procedures whereas two developed spontaneously. CONCLUSION: This analysis shows that the occurrence of severe intraoperative complications can be minimized if certain guidelines are followed. When operating in an anterior-posterior direction, one should, to the extent possible, preserve the ethmoid bulla and the middle turbinate as anatomical landmarks as long as possible. The ethmoid bulla indicates the upper margin of the infundibulum even after removal of the uncinate process. There is no danger of injuring orbital structures if one identifies the maxillary ostium on a line going parallel to the floor of the main nasal cavity from the lowest point of the bulla in a posterior direction. The anterior wall of the bulla also forms the posterior wall of the frontal recess. As long as it is preserved it protects the base of the skull when identifying the frontal ostium. The endonasal enlargement of the frontal sinus ostium as a frontal sinus drainge type II or III is safe if the spina nasalis frontalis and the base of the frontal sinus are removed with a drill in an anterior direction. When opening the ethmoid sinus in an anteroposterior direction, an additional imaginary line through the ethmoid bulla running parallel to the floor of the nasal cavity and therefore also to the base of the skull should be observed and not crossed cranially. The medial blade of the middle turbinate represents an important guide to protect the rima olfactoria. It must therefore be preserved. Exposure of the sphenoid sinus should always be performed transnasally near to the septum and below the sphenoid ostium but never through the ethmoid to prevent damage of the optic nerve or the carotid artery. Observation of these guidelines and anatomical structures will prevent mistakes and wrong approaches in the context of endonasal surgery.
Chronic sinusitis: the role of imaging.
Ide C, Trigaux JP, Eloy P.
Catholic University of Louvain (UCL), Cliniques Universitaires UCL de Mont-Godinne, Department of Radiology, Yvoir, Belgium.
In recent years, routine endoscopic examination of the nose and advances in medical imaging have led to a better understanding of the pathophysiology of chronic sinusitis and the development of "FESS". The CT san of the sinuses have superseded the conventional standard radiography in the evaluation of the paranasal sinuses as it offers more precise anatomic information to the surgeon on the complex anatomy of the sinus cavities and their drainage pathways, in particularly the ostiomeatal complex. The coronal plane is the best incidence because it most closely correlates with the surgical approach. The utilization of a high resolution bony algorithm is recommended. A window of intermediate type, 2500 with a center of 250 HU, is sufficient for nearly all diagnosis. Complementary direct axial sections are needed by the surgeon to guide the approach to the sphenoid sinus and the posterior ethmoidal cells. MRI plays a limited role in the evaluation of a non complicated sinusitis. But MRI has supplanted the CT scanner in the appreciation of intracranial and orbital complications of sinusitis because it provides better visualisation and differentiation of soft tissues than the CT scan. The injection of contrast is recommended in all cases of complicated sinusitis.
Headaches and sinus disease: the endoscopic approach.
Stammberger H, Wolf G.
University ENT Clinic, Graz, Austria.
Headaches can be of sinugenic origin even if this cause may not be suspected from the case history. Endoscopy of the lateral nasal wall with rigid cold light endoscopes in combination with polytomography or computed tomography usually will reveal the underlying causes hidden from the unaided eye, the operating microscope, and standard x-ray examination. Small lesions in the lesser cells of the ethmoid complex may give rise to headaches, especially when located in the key areas of the ethmoid infundibulum or frontal recess. Many anatomic variations of the structures in the middle meatus can narrow the stenotic clefts even more and thus predispose to more or less intense contact of opposing mucosal surfaces. This may impede or block ventilation and drainage of the ethmoid and surrounding larger sinuses and thus affect those as well. After identification of these underlying causes, functional endoscopic sinus surgery with usually minimal operations often can provide dramatic relief of symptoms that may have been present for months or even years. The neuropeptides recently were newly identified as a group of mediators besides the neurotransmitters noradrenalin and acetylcholine. Substance P (SP) is one of the most important neuropeptides that we can identify in the human nasal mucosa. It mediates pain impulses to the cortex via afferent C fibers. Simultaneously from polymodal receptors in the nasal mucosa, local reflexes are mediated by SP via an axon reflex, causing vasodilatation, plasma extravasation ("neurogenic edema"), and hypersecretion. The receptors can be stimulated by chemical and caloric irritants and also mechanical irritants such as pressure. The pressure exerted on nasal mucosa by polyps or mucosal swelling due to other reasons in the ethmoid clefts, cells, and narrow spaces apparently can be enough to trigger an SP-mediated pain sensation via afferent C fibers. Over the axon reflex an initially small lesion may lead in a vicious circle to quite significant symptoms. The model of "referred pain" explains why the pain is not necessarily felt at its origin, but may be projected onto corresponding dermatomes. The pain-mediating function of SP can be blocked selectively by capsaicin, the pungent component of red pepper, which leads to desensitization of the receptors and degeneration of the afferent C fibers without affecting other sensory qualities. In patients with vasomotor rhinitis we were able to block all the patients' symptoms including headaches by topical administration of capsaicin. After identification of underlying causes with endoscopy and CT, lesions and contact areas should be operated upon if medical treatment fails.(ABSTRACT TRUNCATED AT 400 WORDS)
[Combined-macro-micro endoscopic technique as the most advantageous endonasal sinus surgery especially for severe sinusitis: theory and surgical technique]
[Article in Japanese]
Kikawada T.
Hamamatsu Ear, Nose and Throat Surgicenter.
Functional endonasal sinus surgery (FESS) is becoming the procedure of choice for the surgical treatment of chronic sinusitis. The operation has been made possible by the introduction of the endoscope to sinus surgery. The endoscope allows a more detailed observation of ethmoid lesions, and provides direct visual access to the paranasal region which is not visible through the anterior nares. A technique which involves the exclusive use of endoscopy, endoscopic sinus surgery, presents several problems however, especially in cases of polyposis or those with excessive bleeding. For ideal sinus surgery, tools must guarantee the greatest possible safety, ease, and accuracy. None of the currently available tools is independently able to fully satisfy all three of these requirements, not even the endoscope. The anatomical region being operated on determines which of these three requirements is most critical in each phase of the surgery. Ease is most important in the nasal cavity, which has no exceptionally dangerous regions to be operated on. The quickest and simplest operation is most expedient for minimizing blood loss in severe polyposis. To achieve this objective, macroscopic manipulation using a headlamp is most suitable. There is no need to use the endoscope or microscope to remove polyps in the nasal cavity. Because almost all of the risks in sinus surgery are encountered in the ethmoid region, operation in this area demands the safest method. For example if the ethmoid cavity is filled with massive polyps, it is sometimes difficult to endoscopically detect whether orbital fat has broken into the ethmoid. To discriminate between fat and a polypoid lesion or to distinguish dura from mucoperiost during surgery, the microscope is clearly the superior tool. In region where dead angles prevent accurate manipulation, use of the endoscope is essential. To optimize success in sinus surgery using the currently available tools, the author describes a combined macro-micro-endoscopic technique (COMMET) which effectively combines use of the headlamp, the microscope, and the endoscope according to the demands of each anatomical region.
An endoscopic study of tubal function and the diseased ethmoid sinus.
Stammberger H.
Diseases of the paranasal sinuses--especially of the anterior ethmoid sinus--may affect tubal function. Acute and chronic sinus inflammations cause alterations in the normal pathways for secretions out of the sinus system. The normal secretion pathways usually bypass the orifice of the eustachian tube in the nasopharynx. Excessive or infected mucus can then be transported directly over the tubal orifice to cause its obstruction and promote ascending infections into the middle ear. We have found that nasal endoscopy proves to be very helpful in detecting even "hidden" pathologies due to sinus disease in key areas in the middle meatus, and furthermore allows a direct visualization of the tubal orifice. Functional endoscopic surgery has also enabled us to clear diseased and stenotic areas involving the sinus ostia with minimal procedures. Normal drainage and ventilation are reestablished via the physiologic sinus ostia and thus help to normalize tubal function.
Endoscopic endonasal sinus surgery. Approaches and post-operative evaluation.
Moriyama H, Ozawa M, Honda Y.
Dept. of O.R.L., Jikei University School of Medicine, Tokyo, Japan.
Recently, by using a rigid endoscope and a VIDEO system (CCD camera and TV monitor) for endonasal sinus surgery, surgical complications have been prevented. This is because a decrease in the dead angles achieves wide and clear visualisation of the site of manipulation of the paranasal sinuses, which have a delicate and complicated structure. Our endonasal sinus procedures under local anaesthesia consist of removal of pathologic mucosa within the anterior and posterior ethmoid sinuses, opening of the cellulae and establishment of sufficient communication between the ethmoid sinus and the maxillary and frontal sinuses. Even if pathologic mucosa is present in the maxillary sinus, we leave it intact and attempt to heal it by achieving good ventilation. The surgical technique often includes correction of septal deviations and conchotomy. In patients with moderate to severe sinusitis (62 cases, 102 examples) who underwent endoscopic endonasal sinusectomy by the same surgeon, X-ray studies of post-operative changes of the maxillary sinus were performed. Fifteen cases showed excellent results, 47 good results, 30 fair results and 10 were unchanged. Clinical symptoms exhibited an overall improvement rate of 73%. Improvement of nasal discharge and nasal obstruction was more easily achieved than improvement of post-nasal discharge.
Isolated sphenoid sinus disease: etiology and management.
Friedman A, Batra PS, Fakhri S, Citardi MJ, Lanza DC.
Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation.
OBJECTIVE: To evaluate the diagnosis and management of isolated sphenoid sinus disease by using the current rhinologic standard of care. STUDY DESIGN: Retrospective chart review. RESULTS: Fifty sequential, symptomatic patients were studied. Presenting symptoms included headache or facial pain (88%), rhinorrhea (46%), and nasal congestion (26%). All patients underwent CT imaging, demonstrating bony changes or dehiscences (42%), a mass (24%), or complete opacification of the sphenoid sinus (22%). Eighty percent required surgical intervention. The most frequent diagnoses were as follows: sinusitis (38%), fungal ball (20%), neoplasm (16%), and mucocele (12%). Treatment resulted in clinical or endoscopic improvement or resolution in 87% of the patients. CONCLUSION: The presenting symptoms of isolated sphenoid sinus disease can be nonspecific and may result in an inordinate delay in diagnosis. Nasal endoscopy and radiologic imaging are central to making an accurate and timely diagnosis. Medical treatment or minimally invasive surgical techniques can successfully manage the majority of patients with persistent or refractory symptoms.
Factors associated with failure of frontal sinusotomy in the early follow-up period.
Chandra RK, Palmer JN, Tangsujarittham T, Kennedy DW.
Department of Otolarygology-Head and Neck Surgery, University of Tennessee School of Medicine, Memphis, USA. RChandraMD@aol.com
OBJECTIVES: To understand factors associated with failure of endoscopic frontal sinusotomy. METHODS: Retrospective review of 130 consecutive frontal sinusotomies. The preoperative extent of disease was graded radiologically in each frontal sinus as total opacification, partial opacification, or mucosal thickening. Records were also reviewed to determine the incidence of comorbid conditions. RESULTS: Patency at most recent follow-up was observed in 117/130 (90%). Patency was achieved after our first procedure in 107 sinusotomies. These were considered successes. Ten required revision surgery, and an additional 13 were not patent at last follow-up. These 23 sinusotomies were considered failures. Among those failing our initial surgery, 19/23 (83%) were partially or totally opacified preoperatively. In contrast, only 47/107 (44%) in the success group contained partial or total opacification preoperatively (P = 0.003), with the majority exhibiting mucosal thickening only. Mean follow-up was 8.3 months for the successes and 10.7 months for the failures (P = NS). No significant differences were observed between the success and failure groups with respect to the prevalence of asthma, aspirin sensitivity, or allergic fungal disease. Patients in the failure group, however, had a higher mean number of prior surgeries before undergoing frontal sinusotomy at our institution (1.8 vs 0.9, P = 0.033). CONCLUSIONS: During the early follow-up period, failure of endoscopic frontal sinusotomy is associated with advanced degrees of preoperative disease within the sinus and is also more likely in patients who have failed prior surgical management.
Recurrence rates after endoscopic sinus surgery for massive sinus polyposis.
Wynn R, Har-El G.
Department of Otolaryngology, SUNY Downstate Medical Center at Brooklyn, Brooklyn, NY 11203, USA.
BACKGROUND AND OBJECTIVES: Most studies on outcome after endoscopic sinus surgery (ESS) include patients with varying degrees of disease severity. Recurrence rates cited by those studies may not apply to the subset of patients with severe polyposis. Our aim is to provide reference information for recurrence rates and need for revision surgery in patients with severe disease. STUDY DESIGN, PATIENTS, AND METHODS: Review of patients with severe polyposis with a minimum Lund-McKay score of 16 and with a Kennedy computed tomography stage 3 or 4. Data collection included demographics, presence of asthma or documented allergy, history of previous surgery, extent of surgery, preoperative and postoperative management, recurrence rates, revision surgery rates, and follow-up. RESULTS: One hundred and eighteen records were reviewed. Fifty-nine (50%) patients had asthma, and 93 (79%) had documented allergy. All patients required extensive bilateral nasal polypectomy, complete anterior and posterior ethmoidectomy, and maxillary sinusotomy. One hundred (85%) also had frontal or sphenoid sinusotomy. Follow-up ranged from 12 to 168 (median 40) months. Seventy-one (60%) developed recurrent polyposis. Fifty-five (47%) were advised to undergo revision surgery, and 32 (27%) underwent surgery. History of previous sinus surgery or asthma predicted higher recurrence (P <.005, P <.001) and revision surgery rates (P =.02, P <.001). History of allergy also predicted recurrence and need for revision (P <.001, P <.001). CONCLUSIONS: Recurrence rates after ESS for severe polyposis are significant. In our study, patients with asthma are at higher risk of recurrence.
Endoscopic surgery for frontal sinusitis--a graduated approach.
Metson R, Sindwani R.
Department of Otology and Laryngology, Harvard Medical School, Zero Emerson Place, Boston, MA 02114, USA. ralph_metson@meei.harvard.edu
Contemporary surgical treatment of patients with frontal sinusitis is based on a graduated approach determined by the patient's history and the extent of disease present. Most patients with inflammatory disease of the frontal sinus respond well to an anterior ethmoidectomy and clearing of agger nasi cells encroaching upon the frontal recess. In more advanced cases, a frontal sinusotomy with enlargement of the ostium may be performed to facilitate frontal sinus drainage and ventilation. For patients in whom conventional endoscopic techniques have not been successful, the floor of the frontal sinus is removed with a drill, usually with the assistance of image-guidance technology. Frontal sinus obliteration is reserved for patients with advanced disease for whom endoscopic management has been unsuccessful. Although patients with refractory frontal sinusitis can present a therapeutic challenge, proper surgical management usually results in successful control of symptoms and overall improvement in quality of life.
Use of the 70-degree diamond burr in the management of complicated frontal sinus disease.
Chandra RK, Schlosser R, Kennedy DW.
Department of Otolaryngology-Head and Neck Surgery, University of Tennessee School of Medicine, 956 Court Avenue, Suite B226, Memphis, TN 38163, USA. RChandraMD@aol.com
OBJECTIVES/HYPOTHESIS: Management of frontal sinus disease may require drill-out of bone in the frontal recess for access, ventilation, and drainage of the sinus cavity; removal of osteitic foci; or resection of neoplastic tissue. Technological advances, particularly burrs with angles of 70 degrees and stereotactic navigational imaging, offer new opportunities to provide access and minimize trauma. The preliminary study evaluates the safety and efficacy of such minimally invasive approaches. STUDY DESIGN: Retrospective review. METHODS: The authors describe the use of a 70-degree diamond burr in a series of 10 patients with complicated frontal sinus disease who underwent endoscopic frontal sinusotomy under stereotactic imaging guidance. RESULTS: The diagnoses consisted of frontal sinus mucocele (n = 4), chronic frontal sinusitis (n = 1), Pott's puffy tumor after frontoethmoid fracture (n = 1), and recurrent inverting papilloma (n = 4). Partial septectomy was required in 6 of 10 patients. No complications were attributable to the drill-out procedure, despite a pre-existing frontoethmoid bony dehiscence in 6 of 10 patients. One patient had a CSF leak during removal of tumor from the skull base. One patient required revision frontal sinusotomy 10 months after the initial procedure, and another required further surgery for residual inverting papilloma on the medial orbital wall. All frontal sinusotomies were patent at last follow-up (mean period, 9.3 mo). CONCLUSION: Extended endoscopic frontal sinusotomy may be necessary in the management of complicated frontal sinus inflammatory disease and inverting papilloma. The 70-degree diamond burr is a safe and effective tool for access to the frontal recess. Complication rates appear to be similar to those for other extended frontal sinusotomy approaches.
[Endoscopic resection of the frontal sinus floor following the Draf procedure: long term results and therapeutic algorithm]
[Article in French]
Petelle B, Sauvaget E, Kici S, Tran Ba Huy P, Herman P.
Service ORL et de Chirurgie Maxillo-Faciale et Plastique, Hopital Lariboisiere, 2 rue Ambroise Pare, 75475 Paris Cedex 10. boris.petelle@lrb.ap-hop-paris.fr
OBJECTIVES: Endoscopic resection of the frontal sinus floor is a minimally invasive and functional surgical procedure designed for the treatment of inflammatory sinus diseases, which avoids the side-effects of external osteoplastic obliteration. The aim of the study was to evaluate long term results and to determine computed tomographic criteria predictive of success. PATIENTS AND METHODS: Our study reports the results of 20 patients operated for nasofrontal stenosis associated or not with osteitis or secondary mucocele. RESULTS: A successful result was obtained in 90% with a mean follow-up of 3.5 years. Failures (2) were attributed to insufficient resection and to frontal sinus osteogenesis. CONCLUSION: Endoscopic frontal sinusotomy is a safe and effective procedure for large sinuses with large distance between nasion and cribriform plate, but not in case of osteogenesis and multiple mucoceles. In case of unfavourable anatomy, or for the aforementioned pathologies, the obliteration procedure should be preferred.
The five year experience with endoscopic trans-septal frontal sinusotomy.
Lanza DC, McLaughlin RB Jr, Hwang PH.
Section of Nasal and Sinus Disorders, Department of Otolaryngology and Communicative Disorders, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
Endoscopic trans-septal frontal sinusotomy (TSFS) represents a unique surgical approach to the floor of the frontal sinus. Although the final result can have similarities to the modified Lothrop procedure in that the intersinus septum may be drilled out, endoscopic TSFS represents a novel approach that can be valuable in patients with certain anatomic configurations. Endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist to augment treatment of refractory frontal sinus disease. This procedure is best considered for patients with favorable anatomy who have significant frontal sinus disease and cannot be managed adequately through an endoscopic frontal sinusotomy.
Modern concepts of frontal sinus surgery.
Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD.
Department of Otorhinolaryngology, Head and Neck Surgery, Facial Plastic Surgery, and Communication Disorders, Fulda Hospital, Academic Teaching Hospital of the University of Marburg, Germany. rainer-K-weber@t-online.de
OBJECTIVES/HYPOTHESIS: To validate the endonasal surgical approach to frontal sinus in inflammatory sinus disease, trauma, and selective tumor surgery, and to define the role of external approaches to the frontal sinus. Endonasal frontal sinusotomy can range from endoscopic removal of obstructing frontal recess cells or uncinate process to the more complex unilateral or bilateral removal of the frontal sinus floor as described in the Draf II-III drainage procedures. In contrast, the osteoplastic frontal sinusotomy remains the "gold standard" for external approaches to frontal sinus disease. METHODS: A retrospective review of 1286 patients undergoing either endonasal or external frontal sinusotomy by the authors at four university teaching programs from 1977. Prior author reports were updated and previously unreported patient series were combined. RESULTS: Six hundred thirty-five patients underwent type I frontal sinusotomy, 312 type II sinusotomy, and 156 type III sinusotomy. A successful result was seen in these groups, 85.2% to 99.3%, 79% to 93.3%, and 91.5% to 95%, respectively. External frontal sinusotomy or osteoplastic frontal sinusotomy was successfully performed in 187 of 194 patients. Clinical symptoms, endoscopic findings, computed tomography, and magnetic resonance image scanning, and reoperation rate measured postoperative success. CONCLUSIONS: A stepwise approach to the surgical treatment of frontal sinusitis, trauma, and selective benign tumors yields successful results as defined by specific criteria which vary from 79% to 97.8%. The details of specific techniques are discussed, essential points emphasized, and author variations noted.
The frontal sinus rescue procedure: early experience and three-year follow-up.
Kuhn FA, Javer AR, Nagpal K, Citardi MJ.
Georgia Nasal and Sinus Institute, Savannah 31406, USA.
The frontal sinus rescue (FSR), first described in 1997, has now been performed on 24 patients (32 sides) over a period of three years. It is a functional endoscopic surgical approach to correct an iatrogenically scarred and obstructed frontal recess, which cannot be successfully opened via a normal endoscopic frontal sinusotomy approach. It is utilized primarily for patients whose only remaining option is either a Draf-type drill-out (modified intranasal Lothrop) procedure or frontal sinus obliteration. The FSR is a technically challenging procedure, but faster, less difficult, and less destructive for the patient than a "drill-out" or frontal sinus obliteration. Once learned, it can save the patient from undergoing the more radical drill-out or obliterative procedure. The early experience and three-year follow-up with this new endoscopic procedure is presented in our first 24 patients (32 sides).
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